Vascular access for hemodialysis in the elderly

Area of Science:

• Nephrology
• Vascular Surgery
• Geriatrics

Background:

• Elderly patients undergoing hemodialysis (HD) often require vascular access, with arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) being common surgical options.
• Choosing the optimal vascular access is critical for patient outcomes, particularly in older populations with comorbidities.

Purpose of the Study:

• To compare the clinical outcomes of AVFs versus AVGs in a large, population-based cohort of elderly patients (≥75 years) in the United States.
• To evaluate mortality, conduit patency, maturation rates, time to catheter-free dialysis, and infection associated with each access type.

Main Methods:

• Retrospective analysis of patients ≥75 years old from the United States Renal Database System (2007-2011).
• Inclusion of patients with incident AVF, incident AVG, conversion from catheter to AVF or AVG, and those persisting on HD catheters.
• Statistical analysis included chi-squared tests, Student t-tests, Kaplan-Meier analysis, and multivariable Cox regression.

Main Results:

• AVFs demonstrated significantly lower mortality compared to AVG initiates and catheter-persistent patients.
• Primary patency and primary assisted patency were superior for AVFs.
• While AVGs showed higher secondary patency in the initial 4 months, AVFs surpassed them thereafter. AVF maturation rates were comparable to AVGs, but with a shorter time to maturation.

Conclusions:

• Pre-emptive AVF placement is the preferred hemodialysis access for elderly patients who can tolerate surgery, offering the best outcomes.
• For patients initiating HD via catheter, conversion to AVF is recommended if life expectancy exceeds 4 months.
• For patients with limited life expectancy (<4 months), the decision between persistent catheter use or AVG conversion should consider surgical risk and quality of life.