Dialysis Vascular Access Selection in Elderly Patients

Tushar J Vachharajani
European Nephrology, 2011;5(2):152-154
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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 socioeconomic issues. The higher incidence of multiple comorbidities, poor functional capacity, shorter expected lifespan and high mortality rate poses a unique challenge and differentiates this group from their younger counterparts. Hemodialysis remains the most common modality used in this group. Dialysis vascular access surgery and maintenance is challenging and requires a team effort and individualized 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, tunneled catheter, hemodialysis, end-stage renal disease (ESRD), very elderly, dialysis access
Disclosure The author has no conflicts of interest to declare.
Received: September 26, 2011 | Accepted October 10, 2011 | Citation European Nephrology, 2011;5(2):152-154
Correspondence: Tushar J Vachharajani, MD, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. 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 with ESRD in the US are dependent on in-center hemodialysis for their survival.1 However, the percentage of elderly patients receiving alternative renal replacement therapies, such as peritoneal dialysis and renal transplantation, remains small.

The burden of comorbidities and impact of ESRD on life expectancy in the elderly ESRD population bring with them 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 a geo-social environment and differentiates between those living in developed and developing 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 graft (AVG), and tunneled central venous catheter (CVC). Guidelines from the Kidney Disease Outcome Quality Initiative (KDOQI) and from 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, the 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 hemodialysis population. The current approach of ‘fistula first’ does not differentiate between younger and older patients with ESRD.

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