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Dialysis Vascular Access


during a limited time trial with haemodialysis before deciding on long-term commitment. The presence of chronic hypotension is often associated with poor patency of AVF or AVG and might require multiple endovascular or surgical interventions.


An Individualised Approach


CKD care in elderly patients necessitates an open discussion about the risks and benefits of initiating renal replacement therapy. The chronological age by itself is not a good reason to deny dialysis treatment. An open discussion between the patient and caregivers, the nephrologist and the primary care physician is an important and integral part of the treatment plan.27


The discussion should include different


modalities of renal replacement therapy, including alternate therapy such as peritoneal dialysis. Palliative care remains an alternative for patients with a very short life span, and various cultural, educational and geographic factors have a role in the decision process. The palliative care approach is more likely to be considered by nephrologists in the UK and Canada compared with those in the US.28


A clinical score calculation


using nine risk factors has been proposed to predict the six-month mortality in incident elderly dialysis patients to facilitate discussion with the patient and their family members.29


1. US Renal Data System, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2009. Available at: www.usrds.org/ (accessed 28 September 2011).


2. Jassal SV, Trpeski L, Zhu N, et al., Changes in survival among elderly patients initiating dialysis from 1990 to 1999, CMAJ, 2007;177(9):1033–8.


3. Letourneau I, Ouimet D, Dumont M, et al., Renal replacement in end-stage renal disease patients over 75 years old, Am J Nephrol, 2003;23(2):71–7.


4. Vachharajani TJ, Atray NK, Aging veterans and the end-stage renal disease management dilemma in the millennium, Hemodial Int, 2007;11(4):456–60.


5. Kurella M, Covinsky KE, Collins AJ, Chertow GM, Octogenarians and nonagenarians starting dialysis in the United States, Ann Intern Med, 2007;146(3):177–83.


6. Tordoir J, Canaud B, Haage P, et al., EBPG on vascular access, Nephrol Dial Transplant, 2007;22(Suppl 2):ii88–ii117.


7. Fluck R, Kumwenda M, UK Renal Association Clinical Practice Guidelines for Vascular Access, 2008–2011, Final Version, 2011. Available at: www.renal.org/Libraries/Guidelines/Vascular_ Access_for_Haemodialysis_-_FINAL_VERSION_- _05_January_2011.sflb.ashx (accessed 27 September 2011).


8. Vascular Access Work Group, Clinical practice guidelines for vascular access, Am J Kidney Dis, 2006;48(Suppl 1):S248–S73.


9. oly D, Anglicheau D, Alberti C, et al., Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes, J Am Soc Nephrol, 2003;14(4):1012–21.


10. Rohrich B, Asmus G, von Herrath D, Schaefer K, Is it worth performing kidney replacement therapy on patients over 80? Nephrol Dial Transplant, 1996;11(12):2412–3.


Once haemodialysis is chosen as the preferred modality, finalising an ideal dialysis vascular access in the elderly patient with ESRD poses a unique challenge. The vascular access guidelines lack specific recommendations for the best possible solution for elderly patients. The selection of an ideal vascular access in this population needs to be individualised and to implement a common sense approach (see Figure 1). The need to incorporate assessment of functional status, life expectancy, multiple co-morbidities and socioeconomic factors in the vascular access planning cannot be emphasised more. The poor outcomes associated with CVC use even in the elderly population are well known and, unless there is a compelling reason, CVC should therefore be considered only as a final option.


There is no difference in fistula survival in properly selected elderly patients. However, there are, as yet, no data available to assume the superiority of AVF over AVG. The higher incidence of fistula maturation failure resulting in prolonged CVC use might be a reason to consider AVG as an acceptable primary alternative in elderly patients with shorter expected life span and multiple co-morbidities. The ultimate goal, even for elderly patients, is to avoid or reduce the exposure to CVC time. n


11. Peri UN, Fenves AZ, Middleton JP, Improving survival of octogenarian patients selected for haemodialysis, Nephrol Dial Transplant, 2001;16(11):2201–6.


12. Munshi SK, Vijayakumar N, Taub NA, et al., Outcome of renal replacement therapy in the very elderly, Nephrol Dial Transplant, 2001;16(1):128–33.


13. Vachharajani TJ, Moossavi S, Jordan JR, et al., Re-evaluating the Fistula First Initiative in octogenarians on hemodialysis, Clin J Am Soc Nephrol, 2011;6(7):1663–7.


14. Richardson AI, 2nd, Leake A, Schmieder GC, et al. Should fistulas really be first in the elderly patient? J Vasc Access, 2009;10(3):199–202.


15. Kurella M, Chertow GM, Fried LF, et al., Chronic kidney disease and cognitive impairment in the elderly: the health, aging, and body composition study, J Am Soc Nephrol, 2005;16(7):2127–33.


16. Basile C, Lomonte C, Vernaglione L, et al., The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients, Nephrol Dial Transplant, 2008;23(1):282–7.


17. Beigi AA, Sadeghi AM, Khosravi AR, et al., Effects of the arteriovenous fistula on pulmonary artery pressure and cardiac output in patients with chronic renal failure, J Vasc Access, 2009;10(3):160–6.


18. Dhingra RK, Young EW, Hulbert-Shearon TE, et al., Type of vascular access and mortality in U.S. hemodialysis patients, Kidney Int, 2001;60(4):1443–51.


19. Lok CE, Oliver MJ, Su J, et al., Arteriovenous fistula outcomes in the era of the elderly dialysis population, Kidney Int, 2005;67(6):2462–9.


20. Lok CE, Allon M, Moist L, et al., Risk equation determining unsuccessful cannulation events and failure to maturation in


arteriovenous fistulas (REDUCE FTM I), J Am Soc Nephrol, 2006;17(11):3204–12.


21. Lazarides MK, Georgiadis GS, Antoniou GA, Staramos DN, A meta-analysis of dialysis access outcome in elderly patients, J Vasc Surg, 2007;45(2):420–6.


22. Bessias N, Paraskevas KI, Tziviskou E, Andrikopoulos V, Vascular access in elderly patients with end-stage renal disease, Int Urol Nephrol, 2008;40(4):1133–42.


23. Weale AR, Bevis P, Neary WD, et al., Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly, J Vasc Surg, 2008;47(1):144–50.


24. Wasse H, Speckman RA, McClellan WM, Arteriovenous fistula use is associated with lower cardiovascular mortality compared with catheter use among ESRD patients, Semin Dial, 2008;21(5):483–9.


25. Chan MR, Sanchez RJ, Young HN, Yevzlin AS, Vascular access outcomes in the elderly hemodialysis population: A USRDS study, Semin Dial, 2007;20(6):606–10.


26. Wasse H, Speckman RA, Frankenfield DL, et al., Predictors of delayed transition from central venous catheter use to permanent vascular access among ESRD patients, Am J Kidney Dis, 2007;49(2):276–83.


27. Moss AH, Shared decision-making in dialysis: the new RPA/ASN guideline on appropriate initiation and withdrawal of treatment, Am J Kidney Dis, 2001;37(5):1081–91.


28. McKenzie JK, Moss AH, Feest TG, et al., Dialysis decision making in Canada, the United Kingdom, and the United States, Am J Kidney Dis, 1998;31(1):12–8.


29. Couchoud C, Labeeuw M, Moranne O, et al., A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease, Nephrol Dial Transplant, 2009;24(5):1553–61.


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EUROPEAN NEPHROLOGY


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