Hemodialysis access planning and outcomes in older adults

The rate of end-stage kidney disease (ESKD) is steadily rising in the United States, and older adults (ie, 65 years and older) represent the fastest-growing segment in need of hemodialysis. This demographic shift presents unique challenges due to age-related comorbidities, frailty, and increased procedural risks. Despite these challenges, there is limited guidance for risk stratification and management of renal replacement therapy in older patients with ESKD. The authors provide a review of current literature and tools to characterize high-risk older patients with ESKD, focusing on the following three key considerations when planning for permanent hemodialysis access placement: vascular anatomy, frailty, and ESKD Life-Plan considerations. Within this population of older patients, consideration of areas of focus for the history and physical examination, preoperative vascular imaging studies, hemodialysis access type, timing of access placement, type of anesthesia used, and multidisciplinary teams are discussed. Our findings suggest that applying a systematic approach to care that incorporates these key considerations may present a route for improving outcomes in this vulnerable population; however, further research is needed.