Arteriovenous fistula patency loss not greater for older vs younger patients on dialysis
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Published findings indicated that while patients 77 years or older had lower likelihoods of arteriovenous fistula placement and maturation, those who experienced maturation did not have greater rates of patency loss than younger patients.
According to Joyce Z. Qian, PhD, of the Medical Technology and Practice Patterns Institute and the Bloomberg School of Public Health, and colleagues, matured arteriovenous fistulas (AVFs) provide a beneficial alternative to arteriovenous grafts (AVGs) for older patients on dialysis, as these grafts achieve longer patency and require fewer interventional procedures to maintain functionality. However, the researchers acknowledged AVFs need more interventions to achieve maturation in the short term compared with AVGs, which often leads to prolonged central venous catheter (CVC) use and higher infection rates.
“Older patients, especially those who are likely to have short life expectancy and worse AVF outcomes, face the dilemma of whether they should have an AVF or AVG placed as the primary vascular access,” the researchers wrote. “To date, there is no clear clinical recommendation for AVF placement using age as a criterion and the clinical decision is left to the individual vascular surgeon, taking into account the patient’s preference and goals.”
Qian and colleagues analyzed data from the U.S. Renal Data System related to 43,851 patients who initiated dialysis through a CVC between July 2010 and June 2012.
First observing that patients 77 years or older had significantly lower probabilities of both AVF placement and maturation than did patients between 66 and 77 years (adjusted cause-specific hazard ratios [HRs] of 0.96 and 0.95), researchers subsequently found no association between age and AVF primary or secondary patency loss (adjusted cause-specific HRs of 1.05 and 1.06, respectively).
“This [study] highlights the importance of individualized vascular access planning focusing on the likelihood of AVF maturation,” Qian and colleagues concluded. “The chance of AVF maturation estimated based on patients’ demographics, blood vessel configuration, comorbid conditions, functional status and life expectancy may inform the optimal vascular access for older hemodialysis patients.”
Perspective
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Timothy A. Pflederer, MD, FASN, FASDIN
The study by Qian and colleagues recently published in American Journal of Kidney Diseases is both obvious and particularly important.
In a review of outcomes of nearly 44,000 incident dialysis patients older than 67 years, they found those older than 77 years had lower rates of placement of native fistulae and lower rates of maturation for use. Our patients learned this the hard way during the past 10 years of the fistula first initiative. Don’t get me wrong. That initiative was sorely needed. Prior to 1991, surgeons placed arteriovenous grafts in the vast majority of patients without concern for who might be better served with native access. A functional fistula is better than a graft with lower rates of infection, fewer maintenance procedures and longer useful life; but getting to a functional fistula is a complex process and along the way, our singular focus on placing a fistula led to many additional maturation procedures, morbidity from prolonged catheter use and failed fistulae requiring additional surgery – especially in the elderly. The fistula-first initiative importantly focused us on utilizing this superior access, but there were casualties along the way. Qian and colleagues confirmed what we have already learned – a fistula is not the best access for everyone.
The most recent KDOQI guidelines which focus on establishing the right access, in the right patient, at the right time as part of an overall end-stage kidney disease life plan are an important corrective. Not all patients should have an attempt at AVF. Tailor the access to the unique patient and situation.
But the Qian and colleagues study also points us to something very important – the other side of the coin. Many elderly patients can benefit from placement of an AVF. Just as not everyone should get a fistula – there is no age cohort where everyone should be excluded from this “gold standard” access. Their study demonstrates that the properly selected elderly individual with a functional fistula gets all the benefit of their younger counterparts. Primary and secondary patency of those fistulae is similar across all ages – even the very elderly. Public or private payer policy should not exclude groups of patients from the best dialysis access for their individual needs based upon age or any other criteria. However, there is a tendency for payers to do just that.
An example is a recent proposed Local Carrier Decision (LCD) by National Government Services (NGS) for payment coverage for percutaneous fistula placement. (https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=38572&ContrId=297&ver=15&ContrVer=1&CntrctrSelected=297*1&Cntrctr=297&name=&DocType=5&bc=AAACAAYAAAAA&).
While not excluding patients from coverage based upon age, NGS has proposed to not pay for a fistula in patients with class 3 or 4 heart failure. Upon what data is such a broad stroke precluding fistula placement justified?
This study and others make it clear that our patients deserve careful evaluation and consideration of the best dialysis access for their unique needs. This indeed may be a native AVF even in the properly selected very elderly or otherwise complex individual.
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