Vascular access for hemodialysis in the elderly

Isibor J Arhuidese; Michol A Cooper; Muhammad Rizwan; Besma Nejim; Mahmoud B Malas

doi:10.1016/j.jvs.2018.05.219

Vascular access for hemodialysis in the elderly

J Vasc Surg. 2019 Feb;69(2):517-525.e1. doi: 10.1016/j.jvs.2018.05.219.

Authors

Isibor J Arhuidese¹, Michol A Cooper², Muhammad Rizwan³, Besma Nejim³, Mahmoud B Malas⁴

Affiliations

¹ Division of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md; Division of Vascular Surgery, University of South Florida, Tampa, Fla.
² Division of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md; Division of Vascular Surgery, Massachusetts General Hospital, Boston, Mass.
³ Division of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md.
⁴ Division of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.

PMID: 30683199
DOI: 10.1016/j.jvs.2018.05.219

Abstract

Objective: The objective of this study was to compare the outcomes of arteriovenous fistulas (AVFs) with arteriovenous grafts (AVGs) in a large population-based cohort of elderly patients in the United States.

Methods: A retrospective analysis was performed of all patients ≥75 years old in the prospectively maintained United States Renal Database System who had an AVF or AVG placed for hemodialysis (HD) access between January 2007 and December 2011. Outcomes were mortality, conduit patency, maturation, time to catheter-free dialysis, and infection. A χ² test, Student t-test, Kaplan-Meier analysis, and multivariable Cox regression analysis were employed.

Results: Of the 124,421 patients studied, there were 19,173 (15%) AVF initiates, 4480 (4%) AVG initiates, 29,872 (24%) AVF converts, 10,712 (9%) AVG converts, and 59,824 (48%) patients who persisted on HD catheters. Compared with AVF initiates, relative mortality was significantly higher for AVG initiates (adjusted hazard ratio [aHR], 1.24; P < .001), AVF converts (aHR, 1.36; P < .001), AVG converts (aHR, 1.62; P < .001), and catheter-persistent patients (aHR, 2.23; P < .001). Primary patency (aHR, 1.21; P < .001) and primary assisted patency (aHR, 1.31; P < .001) were higher for AVF. Secondary patency was higher for AVGs within the first 4 months (aHR, 1.12; P < .001) but higher for AVFs beyond that time point (aHR, 1.25; P < .001). Maturation rate and median time to maturation were 80% vs 84% (P < .001) and 46 vs 26 days (P < .001) for AVF vs AVG.

Conclusions: Pre-emptive AVF remains the best mode of HD in elderly patients who can tolerate surgery. Patients who cannot tolerate pre-emptive surgery or have to initiate HD on an urgent basis with a catheter should convert to AVF when it is feasible if life expectancy is >4 months. If life expectancy is <4 months, surgical risk and quality of life should be considered in making the decision to persistently dialyze through HD catheter or to convert to AVG.

Keywords: Age; Arteriovenous fistula; Ateriovenous graft; Autogenous fistula; Elderly; Hemodialysis access; Hemodialysis catheter; Prosthetic graft.

Publication types

Comparative Study

MeSH terms

Age Factors
Aged
Aged, 80 and over
Arteriovenous Shunt, Surgical* / adverse effects
Blood Vessel Prosthesis Implantation* / adverse effects
Catheterization, Central Venous
Clinical Decision-Making
Databases, Factual
Female
Graft Occlusion, Vascular / etiology
Graft Occlusion, Vascular / physiopathology
Humans
Kidney Failure, Chronic / diagnosis
Kidney Failure, Chronic / physiopathology
Kidney Failure, Chronic / therapy*
Life Expectancy
Male
Patient Selection
Quality of Life
Renal Dialysis*
Retrospective Studies
Risk Factors
Time Factors
Treatment Outcome
United States
Vascular Patency