Should fistulas really be first in the elderly patient?

The Kidney Disease Outcomes and Quality Initiative (K/DOQI) has developed guidelines from available data suggesting that arteriovenous fistulas (AVF) be performed in the majority of patients. Patient demographics were not included nor suggested in their recommendations. The purpose of this study is to analyze the outcomes of elderly patients, age greater than 70, undergoing first-time permanent access surgery.

A retrospective review of consecutive patients undergoing new, first time access procedures from January 2005 through December 2005 was performed. Patients with previous attempts at permanent Arteriovenous (AV) access were removed from analysis. Standard statistical methods were used and patency was determined with Kaplan-Meier curves.

One hundred and sixty eight patients underwent first time AVF, 48 of whom were older than 70 years of age. Comparing elderly patients to younger ones, the 12 month primary assisted patency was 35% and 67%, respectively (p=0.002) and secondary patency was 36% and 67%, respectively (p=0.004). Of the 48 elderly patients, 48% had died in the subsequent follow up period as compared to just 20% of the 120 patients younger than 70. The 18-month survival for the elderly group was 50% versus 74% for the younger patients (p=0.004). Of the elderly group who died, the average time to death was 13.1 months and only 8 AVF were able to be accessed. Similar intervention rates per year were seen in both groups.

With an aging population, more patients older than 70 are being evaluated for permanent vascular access. This group poses a difficult dilemma for surgeons attempting to adhere to K/DOQI guidelines. In light of the increased mortality and decreased patency of AVF, this data questions which form of permanent access should be first-line treatment in this subgroup of patients.

This data suggest in the elderly patients, autogenous fistulas may not be the best option for this set of patients.