Dialysis Vascular Access
Dialysis Vascular Access Selection in Elderly Patients Tushar J Vachharajani
Director, Dialysis Access Group of Wake Forest University and Associate Professor of Medicine, Section of Nephrology, Winston-Salem
Abstract
Elderly patients with end-stage renal disease (ESRD) constitute the fastest growing group in the US. The ESRD management in this group entails significant ethical, clinical and socio-economic issues. The higher incidence of multiple co-morbidities, poor functional capacity, shorter expected life span and high mortality rate poses a unique challenge and differentiates this group from their younger counterparts. Haemodialysis remains the most common modality used in this group. Dialysis vascular access surgery and maintenance is challenging and requires a team effort and individualised approach. In properly selected patients, fistula creation might be expected to work as well as in the younger population. However, synthetic grafts might be a reasonable alternative, especially if they reduce the exposure time to central venous catheters.
Keywords
Elderly, renal dialysis, arteriovenous fistula, arteriovenous graft, central venous catheter, tunnelled catheter, haemodialysis, end-stage renal disease (ESRD), very elderly, dialysis access
Disclosure: The author has no conflicts of interest to declare. Received: 26 September 2011 Accepted: 10 October 2011 Citation: European Nephrology, 2011;5(2):152-4 Correspondence: Tushar J Vachharajani, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157, US. E:
tvachhar@wakehealth.edu
The fastest-growing dialysis population in the US over the past two decades has been patients aged 65 years and above.1
Since 2000, the
adjusted end-stage renal disease (ESRD) incident rate in those aged 75 and older has also increased, by 11 %, to 1,744 patients per million individuals.1
Most elderly patients in the US with ESRD are dependent on in-centre haemodialysis for their survival.1
However, the
percentage of elderly patients receiving alternate renal replacement therapies, such as peritoneal dialysis and renal transplantation, remains small.
The burden of co-morbidities and impact of ESRD on life expectancy in the elderly ESRD population brings with it unique challenges for treatment. The definition of ‘elderly’ is not consistent and needs to be clarified before making treatment plans. The WHO defines ‘elderly’ in the context of geo-social environment and differentiates between those living in developed and underdeveloped countries. The conventional definition of ‘elderly’ based solely on a chronological age of more than 65 years is certainly not sufficient, at least in developed countries. The ‘very elderly’ population (more than 75 years) faces issues that are different from the conventional ‘elderly’ population. Along with ethical and socioeconomic issues, the impact of ESRD on life expectancy in the very elderly is greatest and remains an important factor in deciding about dialysis therapy.2–5
Factors Influencing Vascular Access in the Elderly
There are three main types of dialysis vascular access used in the elderly patients with ESRD – arteriovenous fistula (AVF), synthetic arteriovenous grafts (AVG) and tunnelled central venous catheters (CVC). Guidelines from the Kidney Disease Outcome Quality Initiative
152
(KDOQI) and several other countries recommend AVF as the access of first choice based on the reduced associated morbidity and mortality compared with AVG and CVC.6–8
In the US, establishment of the Fistula
First Breakthrough Initiative (FFBI;
www.fistulafirst.org) promoted the concept of creating AVF as the primary vascular access in the incident and prevalent haemodialysis population. The current approach of ‘fistula first’ does not differentiate between younger and older patients with ESRD.
The data on creating a successful and functional AVF in the elderly patient are conflicting, primarily because the definition of ‘elderly’ is not consistent. Moreover, the studies reporting successful placement of AVF in the elderly population might be biased by being retrospective and probably identifying the healthier elderly patients. The lack of prospective studies makes it difficult to provide definitive practice guidelines. The planning of a vascular access in elderly patients is complex and needs to consider the associated factors discussed below before making a final decision (see Table 1).
The elderly ESRD population is frail and their survival outcome depends on their nutritional status, ambulatory status, advanced chronological age and associated co-morbid conditions, especially cardiovascular disease.9
The choice of vascular access also depends
on their anticipated life expectancy. Several studies have reported relatively poor survival among the elderly dialysis population.10–12 Kurella et al. reported the one-year survival rate in octogenarians and nonagenarians to be 54 % after initiating dialysis, which is lower than the age-matched population.5
The shorter lifespan might not provide
adequate time for the AVF to mature and, therefore, might not be the preferred vascular access.13,14
© TOUCH BRIEFINGS 2011
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