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AVFs may not be the best access for elderly patients with ESRD
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Given a limited time on dialysis and poor vasculature, elderly patients initiating hemodialysis therapy may face more access-related complications with an arteriovenous fistula than with an arteriovenous graft, a study shows.
“National vascular access guidelines recommend placement of arteriovenous fistulas (AVFs) over grafts (AVGs) in hemodialysis patients, but have not been comprehensively assessed in the elderly,” wrote Timmy Lee, MD, MSPH, from the division of nephrology in the department of medicine at the University of Alabama at Birmingham, and colleagues from the Veterans Affairs Medical Center in Birmingham and the Medical Technology and Practice Patterns Institute in Bethesda, Md. “We evaluated clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation.”
Researchers looked at claims data from the U.S. Renal Data System of 9,458 patients who were 67 years or older and started hemodialysis therapy with a catheter from July 1, 2010 to June 30, 2011 and received an AVF (n = 7,433) or an AVG (n = 2,025) within the first 6 months after initiating dialysis. The focus of the data analysis was to determine successful use of the selected vascular access, the number and frequency of interventions needed to make the vascular access functional, time needed for the patient to be dependent on the catheter before successful use of the permanent vascular access and a review of the number of accesses that had to be abandoned.
Researchers found that “unsuccessful use of the selected vascular access within 6 months of creation was higher for AVFs vs. AVGs (51% vs. 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99),” they wrote and “Interventions to make vascular access functional were greater in AVFs vs. AVGs (42% vs. 23%; OR, 2.66; 95% CI, 2.26-3.12).“ However, “AVFs had a lower 1-year abandonment rate after successful use compared with AVGs (OR, 0.71; 95% CI, 0.62-0.83) and required one-fourth fewer interventions after successful use (relative risk, 0.75; 95% CI, 0.69-0.81).” Patients who did receive an AVF depended on a catheter substantially longer before the permanent access became functional compared to those receiving an AVG (median time, 3 months vs. 1 month).
Considering the compromised vasculature of the elderly and slower recovery time – as well as the likely shorter time on dialysis therapy – choosing an AVF for an access in the elderly patient is a different decision-making process than it was when the Fistula First initiative began in 2002, the authors noted. Recommendations at the time for increasing the placement of AVFs was “when only 24% of U.S. patients were dialyzing with an AVF, unsuccessful use of AVFs for dialysis was relatively infrequent (20% to 30%) and AVFs requiring interventions to make the AVF functional were also relatively uncommon,” they wrote. “As a consequence of patient selection, vascular access longevity after successful use was clearly superior for AVFs as compared with AVGs. Fifteen years later, now that AVFs are placed in most patients (78% of the current study cohort of elderly incident hemodialysis patients), their advantages over AVGs are not as evident in the elderly hemodialysis population.” – by Mark E. Neumann
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