Renal Replacement Therapy in the Elderly

Vascular access placement and mortality in elderly incident hemodialysis patients

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.

Outcomes of arteriovenous fistula for hemodialysis in octogenarian population

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.

Management of ethical issues related to care of seriously ill dialysis patients in free-standing facilities

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.

Creation of Autogenous Radial Cephalic Direct Wrist Access for Hemodialysis in the Elderly Using Microsurgery

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.