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Outcomes of Elderly Patients after Predialysis Vascular Access Creation

Timmy Lee1, Mae Thamer2, Yi Zhang2

  • 1Division of Nephrology, Department of Medicine, University of Alabama, Birmingham, Alabama; Veterans Affairs Medical Center, Birmingham, Alabama; and.

Journal of the American Society of Nephrology : JASN
|April 10, 2015
PubMed

Insights

Most elderly patients with advanced chronic kidney disease (CKD) start dialysis within two years of permanent vascular access creation. However, arteriovenous grafts (AVGs) may be a catheter-sparing option for selected patients due to arteriovenous fistula (AVF) maturation failures.

Area of Science:

  • Nephrology
  • Vascular Surgery
  • Geriatric Medicine

Background:

  • Uniform vascular access guidelines may not suit elderly patients due to competing mortality risks and high arteriovenous fistula (AVF) maturation failure rates.
  • Outcomes for elderly patients with advanced chronic kidney disease (CKD) receiving permanent vascular access before dialysis initiation remain unclear.

Purpose of the Study:

  • To assess dialysis initiation, pre-dialysis death, and dialysis-free survival in elderly patients (≥70 years) undergoing predialysis arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation.
  • To evaluate the rates of functioning access at dialysis initiation and catheter dependence in this population.

Main Methods:

  • Analysis of a large, nationally representative cohort of 3418 elderly patients with CKD undergoing predialysis AVF or AVG creation between 2004 and 2009.
  • Assessment of dialysis initiation, death before dialysis, and dialysis-free survival within 2 years post-access creation.

Main Results:

  • 67% of AVF and 71% of AVG patients initiated dialysis within 2 years; initiation rates varied by age and race.
  • Only half of patients started dialysis with a functioning AVF or AVG; 46.8% of AVFs were placed <90 days before dialysis.
  • Catheter dependence at dialysis initiation was higher with predialysis AVF (46.0%) versus AVG (28.5%).

Conclusions:

  • Most elderly patients with advanced CKD initiate dialysis within 2 years of predialysis vascular access placement.
  • Late placement or maturation failure of AVFs leads to nearly half of patients initiating dialysis with a catheter.
  • Arteriovenous grafts (AVGs) placed closer to dialysis initiation may offer a catheter-sparing approach, potentially delaying permanent access in select elderly CKD patients.

Keywords:
arteriovenous fistulaarteriovenous graftvascular access

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