Optimal Hemodialysis Vascular Access in the Elderly Patient

Kidney Clinical Research Unit, Division of Nephrology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada Division of Nephrology, Department of Medicine, Toronto General Hospital, and the University of Toronto, Toronto, Ontario, Canada Division of Nephrology,W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina Department of Nephrology and Department of Medicine, Monash Medical Centre & Monash University, Melbourne, Victoria, Australia Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio.
Seminars in Dialysis (Impact Factor: 1.75). 11/2012; 25(6):640-648. DOI: 10.1111/sdi.12037
Source: PubMed


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.

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