Optimal Hemodialysis Vascular Access in the Elderly Patient
ABSTRACT The optimal vascular access for elderly patients remains a challenge due to the difficulty balancing the benefits and risks in a population with increased comorbidity and decreased survival. Age is commonly associated with failure to mature in fistula and decreased rates of primary and secondary patency in both fistula and grafts. In the elderly, at 1 and 2 years, primary patency rates range from 43% to 74% and from 29% to 67%, respectively. Secondary patency rates at 1 and 2 years range from 56% to 82% and 44% to 67%, respectively. Cumulative fistula survival is no better than grafts survival when primary failures are included. Several observational studies consistently demonstrate a lower adjusted mortality among those using a fistula compared with a catheter; however, catheter use in the elderly is increasing in most countries with the exception of Japan. Both guidelines and quality initiatives do not acknowledge the trade-offs involved in managing the elderly patients with multiple chronic conditions and limited life expectancy or the value that patients place on achieving these outcomes. The framework for choice of vascular access presented in this article considers: (1) likelihood of disease progression before death, (2) patient life expectancy, (3) risks and benefits by vascular access type, and (4) patient preference. Future studies evaluating the timing and type of vascular access with careful assessments of complications, functionality, cost benefit, and patients' preference will provide relevant information to individualize and optimize care to improve morbidity, mortality, and quality of life in the elderly patient.
- Journal of the American Society of Nephrology 06/2013; DOI:10.1681/ASN.2013050507 · 9.47 Impact Factor
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ABSTRACT: Each year a large number of older individuals with advanced renal disease are started on chronic dialysis therapy. Life expectancy is estimated at between 2 and 4 years depending on age, comorbidity, and intensity of medical care required in the weeks around the dialysis start time. Survivors remain at high risk of ongoing morbidity. Regarding quality of life, many older patients express regret over having opted for chronic dialysis therapy and subsequently choose to withdraw from treatment, whereas many others maintain a quality of life similar to that of age-matched peers. Early assessment and ongoing comprehensive geriatric assessment is recommended.08/2013; 29(3):625-639. DOI:10.1016/j.cger.2013.05.005
- Nature Reviews Nephrology 09/2013; 9(11). DOI:10.1038/nrneph.2013.175 · 8.37 Impact Factor