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Ko GJ, Rhee CM, Obi Y, Chang TI, Soohoo M, Kim TW, Kovesdy CP, Streja E, Kalantar-Zadeh K. Vascular access placement and mortality in elderly incident hemodialysis patients. Nephrol Dial Transplant 2020; 35:503-511. [PMID: 30107612 DOI: 10.1093/ndt/gfy254] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/04/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Arteriovenous fistulas (AVFs) are the preferred vascular access type in most hemodialysis patients. However, the optimal vascular access type in octogenarians and older (≥80 years) hemodialysis patients remains widely debated given their limited life expectancy and lower AVF maturation rates. METHODS Among incident hemodialysis patients receiving care in a large national dialysis organization during 2007-2011, we examined patterns of vascular access type conversion in 1 year following dialysis initiation in patients <80 versus ≥80 years of age. Among a subcohort of patients ≥80 years of age, we examined the association between vascular access type conversion and mortality using multivariable survival models. RESULTS In the overall cohort of 100 804 patients, the prevalence of AVF/arteriovenous graft (AVG) as the primary vascular access type increased during the first year of hemodialysis, but plateaued thereafter. Among 8356 patients ≥80 years of age and treated for >1 year, those with initial AVF/AVG use and placement of AVF from a central venous catheter (CVC) had lower mortality compared with patients with persistent CVC use. When the reference group was changed to patients who had AVF placement from a CVC in the first year of dialysis, those with initial AVF use had similar mortality. A longer duration of CVC use was associated with incrementally worse survival. CONCLUSIONS Among incident hemodialysis patients ≥80 years of age, placement of an AVF from a CVC within the first year of dialysis had similar mortality compared with initial AVF use. Our data suggest that initial CVC use with later placement of an AVF may be an acceptable option among elderly hemodialysis patients.
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Affiliation(s)
- Gang Jee Ko
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.,Department of Internal Medicine, Korea University School of Medicine, Seoul, Korea
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Tae Ik Chang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.,Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Korea
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Tae Woo Kim
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.,Department of Internal Medicine, Soon Chun Hyang University Hospital, Gumi, Korea
| | - Csaba P Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN, USA.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA.,Department of Medicine, Tibor Rubin Veteran Affairs Medical Center, Long Beach, CA, USA
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Abstract
Introduction Guidelines have been recommending the use of arteriovenous fistula among the hemodialysis population, but no clear conclusion has emerged with regard to the adequate access type in octogenarians. In this paper, the outcomes of arteriovenous fistula in octogenarian cohort were presented for death-censored cumulative patency rate, complications, and patients’ survival rate. Methods A retrospective review of 88 consecutive arteriovenous fistula interventions in 70 octogenarian patients were performed at one referral institution between January 2010 and June 2014. The patients’ records were analyzed and postoperative complications were documented. Death-censored cumulative arteriovenous fistula patency rates were calculated, and Kaplan–Meier method was used to analyze patient survival for 24 months. Findings: Eighty-eight arteriovenous fistula constructions and six salvage procedures were performed in 70 octogenarians. Fifty-four (61.3%) forearm and 34 (38.7%) upper arm fistulas were created. All types of fistulas had 6-, 12-, 18-, and 24-month death-censored cumulative patency rates of 63.6%, 58.3%, 48.8%, and 41.4%, respectively. The primary failure rate was 40.9%. A total of 15 complications were documented as edema, hematoma/bleeding, infection, distal ischemia, and venous aneurysm, all of which had been treated. Patient survival rates for 12 and 24 months were 68.5% and 58.5%, respectively. Discussion and conclusion: This analysis regarding arteriovenous fistula in octogenarian end-stage renal disease patients figured out equal death-censored cumulative patency compared to nonelderly, and two-year survival rate was acceptable. This study strengthens the argument that arteriovenous fistula should be the best proper choice in selected octogenarians; older age only should not be considered as an absolute contraindication for arteriovenous fistula creation in octogenarians; and patient-based approach should be applied.
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Rodriguez Villarreal I, Ortega O, Hinostroza J, Cobo G, Gallar P, Mon C, Herrero JC, Ortiz M, Di Giogia C, Oliet A, Vigil A. Geriatric Assessment for Therapeutic Decision-Making Regarding Renal Replacement in Elderly Patients with Advanced Chronic Kidney Disease. ACTA ACUST UNITED AC 2014; 128:73-8. [DOI: 10.1159/000363624] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 05/08/2014] [Indexed: 11/19/2022]
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Song MK, Hanson LC, Gilet CA, Jo M, Reed TJ, Hladik GA. Management of ethical issues related to care of seriously ill dialysis patients in free-standing facilities. J Pain Symptom Manage 2014; 48:343-52. [PMID: 24411183 DOI: 10.1016/j.jpainsymman.2013.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/09/2013] [Accepted: 09/15/2013] [Indexed: 11/22/2022]
Abstract
CONTEXT There are few data on the frequency and current management of clinical ethical issues related to care of seriously ill dialysis patients in free-standing dialysis facilities. OBJECTIVES To examine the extent of clinical ethical challenges experienced by care providers in free-standing facilities and their perceptions about how those issues are managed. METHODS A total of 183 care providers recruited from 15 facilities in North Carolina completed a survey regarding the occurrence and management of ethical issues in the past year. Care plan meetings were observed at four of the facilities for three consecutive months. Also, current policies and procedures at each of the facilities were reviewed. RESULTS The two most frequently experienced challenges involved dialyzing frail patients with multiple comorbidities and caring for disruptive/difficult patients. The most common ways of managing ethical issues were discussions in care plan meetings (n = 47) or discussions with the clinic manager (n = 47). Although policies were in place to guide management of some of the challenges, respondents were often not aware of those policies. Also, although participants reported that ethical issues related to dialyzing undocumented immigrants were fairly common, no facility had a policy for managing this challenge. Participants suggested that all staff obtain training in clinical ethics and communication skills, facilities develop ethics teams, and there be clear policies to guide management of ethical challenges. CONCLUSION The scope of ethical challenges was extensive, how these challenges were managed varied widely, and there were limited resources for assistance. Multifaceted efforts, encompassing endeavors at the individual, facility, organization, and national levels, are needed to support staff in improving the management of ethical challenges in dialysis facilities.
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Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Laura C Hanson
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Constance A Gilet
- UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Minjeong Jo
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Teresa J Reed
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gerald A Hladik
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Creation of Autogenous Radial Cephalic Direct Wrist Access for Hemodialysis in the Elderly Using Microsurgery. J Vasc Access 2013; 15:12-7. [DOI: 10.5301/jva.5000165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2013] [Indexed: 11/20/2022] Open
Abstract
Purpose Guidelines recommend autogenous radial-cephalic AV fistula (RCAVF) as the first choice for hemodialysis. Concern has been raised that this is not suitable in the elderly. We assessed the results of microsurgery for RCAVF creation comparatively in patients older and younger than 70 years. Methods We prospectively followed 126 patients for three years. After systematic clinical and ultrasound assessment, a RCAVF was created using a surgical microscope. Patency was assessed immediately, at one week, one month and one year. Outcomes were recorded and stratified into two groups: <70y and >70y. Results RCAVF was created in 75.4% and 70.8% of the <70y and >70y groups, respectively. Incidence of early failure was 11% (<70y) and 13% (>70y). Primary and secondary patency at one year was 67% and 84% (<70y) versus 63% and 80% (>70y). Conclusions Microsurgery enabled the creation of RCAVF in >70y with acceptable risk of failure and slight differences by comparison with <70y. Older age should not preclude RCAVF creation.
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