Optimal Hemodialysis Vascular Access in the Elderly Patient
- 22 November 2012
- journal article
- review article
- Published by Wiley in Seminars in Dialysis
- Vol. 25 (6), 640-648
- https://doi.org/10.1111/sdi.12037
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.Keywords
This publication has 78 references indexed in Scilit:
- Optimizing renal replacement therapy in older adults: a framework for making individualized decisionsKidney International, 2012
- Managing Older Adults With CKD: Individualized Versus Disease-Based ApproachesAmerican Journal of Kidney Diseases, 2012
- Increased Plasma Chymase Concentration and Mast Cell Chymase Expression in Venous Neointimal Lesions of Patients with CKD and ESRDSeminars in Dialysis, 2011
- Severe venous neointimal hyperplasia prior to dialysis access surgeryNephrology Dialysis Transplantation, 2011
- A Randomized, Controlled Trial of Early versus Late Initiation of DialysisThe New England Journal of Medicine, 2010
- Who should be referred for a fistula? A survey of nephrologistsNephrology Dialysis Transplantation, 2010
- Vascular access use and outcomes: an international perspective from the dialysis outcomes and practice patterns studyNephrology Dialysis Transplantation, 2008
- When to refer patients with chronic kidney disease for vascular access surgery: Should age be a consideration?Kidney International, 2007
- Predictors of Delayed Transition From Central Venous Catheter Use to Permanent Vascular Access Among ESRD PatientsAmerican Journal of Kidney Diseases, 2007
- Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid DiseasesJama-Journal Of The American Medical Association, 2005