Vascular access in the elderly: Tradeoffs necessary

Product Quick Finder

Choose a category or subcategory

Vascular access in the elderly: Tradeoffs necessary

According to guidelines on vascular access of hemodialysis patients in the United States (and elsewhere), arteriovenous fistulas (AVFs) are recommended over grafts (AVGs). However, as researchers at the University of Alabama (US) point out, these guidelines have not yet been comprehensively assessed in the elderly (Lee T et al, Tradeoffs in Vascular Access Selection in Elderly Patients Initiating Hemodialysis With a Catheter. Am J Kidney Dis. 2018; doi: 10.1053/j.ajkd.2018.03.023).

The aim of the present study was therefore to evaluate clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation. The main result: There is no clear winner – the choice between the two options is always a tradeoff. The retrospective cohort study was based on claims data from the US Renal Data System, including 9,458 US patients 67 years and older. All patients had initiated hemodialysis therapy with a catheter and received an AVF (n = 7,433) or AVG (n = 2,025) within the following six months.  

  • The unsuccessful use of vascular access within six months of creation was higher for AVFs versus AVGs (51% vs. 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99).
  • Interventions to make vascular access functional were greater in AVFs versus AVGs (42% vs. 23%; OR, 2.66; 95% CI, 2.26-3.12).
  • 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 receiving an AVF had substantially longer catheter dependence before successful use than those receiving an AVG (median time, 3 vs. 1 month; P < 0.001).

The optimal vascular access selection in elderly hemodialysis patients involves tradeoffs between the AVF and the AVG, conclude the authors. AVGs offer shorter catheter dependence and less frequent interventions to make the vascular access functional, while AVFs offer longer access patency and fewer interventions after successful use of the vascular access.

Link to the study: https://www.ajkd.org/article/S0272-6386(18)30634-6/fulltext
 

The aim of the present study was therefore to evaluate clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation. The main result: There is no clear winner – the choice between the two options is always a tradeoff.

The retrospective cohort study was based on claims data from the US Renal Data System, including 9,458 US patients 67 years and older. All patients had initiated hemodialysis therapy with a catheter and received an AVF (n = 7,433) or AVG (n = 2,025) within the following six months.

  • The unsuccessful use of vascular access within six months of creation was higher for AVFs versus AVGs (51% vs. 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99).

  • Interventions to make vascular access functional were greater in AVFs versus AVGs (42% vs. 23%; OR, 2.66; 95% CI, 2.26-3.12).

  • 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 receiving an AVF had substantially longer catheter dependence before successful use than those receiving an AVG (median time, 3 vs. 1 month; P < 0.001).


    The optimal vascular access selection in elderly hemodialysis patients involves tradeoffs between the AVF and the AVG, conclude the authors. AVGs offer shorter catheter dependence and less frequent interventions to make the vascular access functional, while AVFs offer longer access patency and fewer interventions after successful use of the vascular access.

     

     

Link to the study: https://www.ajkd.org/article/S0272-6386(18)30634-6/fulltext