Appropriate vascular access for dialysis patients with limited life expectancy

Vascular access is critical for a patient´s well-being and overall health. The Fistula First Breakthrough Initiative was instrumental in reducing the number of arteriovenous grafts (AVG) and boosting the construction of arteriovenous fistulas (AVF) as the preferred permanent vascular access for hemodialysis.¹ The construction of a distal radiocephalic AVF in the non-dominant arm is the “ideal” vascular access, as initially described by Cimino and Brescia.²

In elderly patients with advanced dementia or severe comorbidities, the possibility of providing only conservative measures and comfort care needs to be contemplated. Similar questions on appropriate timing to initiate dialysis can face the nephrologist, irrespective of the patient age, in the setting of severe neurologic impairment, advanced cancer, decompensated cirrhosis, and other comorbid conditions that dramatically restrict the quantity and quality of life.³

Determining the best access

The decision on which vascular access to choose comes after the decision on the long-term goals and on the expected survival of the patient once dialysis is initiated. We evaluated the patterns of dialysis prescription and vascular access prevalence among 1,247 elderly patients (> 80 years of age) undergoing dialysis in Portugal and Poland and compared the gender differences both in prescription and vascular access. Patients more than 80 years old had a higher prevalence of catheter (26% vs 14%, < 80 years old). Comparing genders, females had fewer AVFs (57% vs 68%). Dialysis prescription and adequate solute removal was adequate in both age groups and in both genders.⁴ Similar results were seen in patients studied in Israel.⁵

A sizable number of patients older than 80 years do experience a fair quality of life on dialysis without cognitive deficits and have very reasonable survival rates. And, despite an increased prevalence of catheters when compared to the younger patients, the majority of them, male and female, have an AVF as their vascular access.

Although the burden of diseases tends to be much heavier in the octogenarians and nonagenarians, paradoxically, sometimes the elderly patient, rather than sick, frail and demented, is a “survivor” with better cardiovascular and general status than some 50–60-year old patients with severe atherosclerosis and other comorbid conditions.

How to evaluate

When evaluating access options for elderly or debilitated patients with advanced kidney disease, there are some questions to ask.

When will dialysis be necessary?

Will the patient die before or shortly after initiating dialysis?

Will he or she tolerate the hemodynamic load of AVF construction both locally (“steal syndrome”) or from a general cardiovascular standpoint?

One of the objections to early construct of an AVF in elderly patients is the fact that death competes with reaching the need to dialyze. In one study, up to 30% of patients with constructed AVF died before needing dialysis.⁶ Furthermore, many of the elderly patients who initiate dialysis after AVF placement still need to start renal replacement through a catheter as AVF often does not develop enough to support hemodialysis. Conversely, an AVG is more likely to develop and to be used in a timely fashion,⁶ and more elderly patients may have a patent, useful access when it was an AVG.^6,7 It can be placed shortly before the need of dialysis initiation, in a time when the actual need to dialyze is more predictable.

Preparing for an access placement

Many nephrologists and vascular surgeons start planning an access placement when the creatinine clearance is between 15 and 20 ml/min/1.73m². They might start with a distal/radiocephalic fistula, with the knowledge that it may not mature. There are arguments that, in the elderly, a proximal (brachiocephalic) AVF is preferable as a first vascular access, due to the high failure rate of an AVF placed distally.

It is important to note that the “vascular surgeon factor” ––the skill and experience of the AVF or AVG creator––is extremely important. This is particularly relevant in placing the complex AVF with transposed basilic veins. Prior Doppler “mapping” of the upper limb’s (or, sometimes, lower limb) arterial and venous system, prior to vascular access placement, is becoming the standard of care to minimize the risks of failure. A lifelong vascular access plan is of paramount importance at all age groups.⁸

The availability of expert interventional radiology to diagnose and treat AVF and AVG dysfunction and thrombosis can be valuable. This may be particularly relevant in the elderly, with excellent primary and secondary patency in vascular accesses of octogenarians and nonagenarians subjected to endovascular interventions as recently described.⁹

Decisions on access choice: A tough task

It is important to remember that the basis of “evidenced-based medicine” is the randomized controlled clinical trial. Due to ethical reasons, nephrologists would not randomly allocate patients to an AVF, AVG, or a catheter and study the long-term clinical results of the three cohorts. This three-way comparison would be the ideal way to prevent bias and confounding and sort out the true impact of the vascular access on patient’s survival. In retrospective analysis, patients with a catheter die more than the ones with AVF and AVG, but we are not comparing the access options fairly. The nephrologist may decide not to request AVF or AVG placement because of the patient’s limited life expectancy. In fact, researchers point to the fact that most of the differential in mortality between catheter versus AVF or AVG, indeed, are due to comorbid conditions.

The previous point does not mean that nephrologists should not aim to energetically reduce the number of catheters, including in elderly patients with a fair life expectancy. The advantages of “non-catheter” access is quite obvious, namely preventing severe bloodborne infections, including devastating damage in cases of endocarditis or spondylodiscitis. Central stenosis/thrombosis is an additional problem. Furthermore, irrespective of age, AVF is the ideal vascular access, due to lower incidence of thrombosis and infection, but unlike the presence of catheters, having an AVG rather than an AVF does not seem to impact survival in the elderly over 80 years.¹⁰

Conclusions

A growing number of elderly patients, as well as patients with severe, life-limiting pathologies reach advanced kidney disease. If the nephrologist, the patient, and family members elect to provide long-term renal replacement therapy, one of the decisions which will have the highest impact on morbidity and quality of life of the patient is the choice of vascular access for dialysis. Common sense needs to be used, as in all areas of medicine. Therefore, if a short survival is expected, the tunneled catheter is the most reasonable choice for a vascular access. Many authors suggest that if the patient is expected to live for more than 180 days, ideally an AVF should be placed, although an AVG may be a quite reasonable alternative. - by André Weigert, MD, PhD

References

National Kidney Foundation/Fistula First Breakthrough Initiative. www.fistulafirst.org

Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966; 275:1089–1092

Chuva T, Maximino J, Barbosa J et al. Cancer and end-stage kidney disease: A death sentence? Port J Nephrol Hypert 2016; 30: 291-297

Weigert A, Jacobson S, Kleophas W el al. The impact of gender on prescription and use of vascular access in elderly patients on hemodialysis: A European hemodialysis multicenter analysis. J Am Soc Nephrol 2016; 27 (335A)

Olsha O, Hijazi J, Goldin I, Shamesh D. Vascular access in hemodialysis patients older than 80 years. J Vasc Surg 2015; 61:177-183.

Vachharajani T, Moossavi S, Jordan J, Vachharajani V, et al. Re-evaluating the Fistula First Initiative in octogenarians on hemodialysis. Clin J Am Soc Nephrol 2011; 6:1663-1667.

Jadlowiec CC, Mannion EM, Lavallee M, Brown MG. Hemodialysis access in the elderly: outcomes among patients older than seventy. Ann Vasc Surg. 2016; 31:77-84

Woo K, Lok CE. New insights into dialysis vascular access: What is the optimal vascular access type and timing of access creation in CKD and dialysis patients? Clin J Am Soc Nephrol. 2016; 11:1487-94.

Azevedo PN, Turmel-Rodrigues L. Never too old for an autogenous dialysis fistula? Results of endovascular interventions in nonagenarians. Semin Dial. 2015; 28:E1-6

De Silva RN, Patibandl BK, Vin Y, et al. Fistula First is not always the best strategy for the elderly. J Am Soc Nephrol 2013; 24:1297-1304.