The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology

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Abstract

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

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Most cited references 54

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Patency rates of the arteriovenous fistula for hemodialysis: a systematic review and meta-analysis.

Angham Al Mutair, Sarah D Kosa, J. Zhang … (2014)

Advantages of the arteriovenous fistula (AVF), including long patency and few complications, were ascertained more than 2 decades ago and may not apply to the contemporary dialysis population. Systematic review and meta-analysis. Estimates were pooled using a random-effects model and sources of heterogeneity were explored using metaregression. Patients treated with long-term hemodialysis using an AVF. English-language studies indexed in MEDLINE between 2000 and 2012 using prospectively collected data on 100 or more AVFs. Age, AVF location, and study location. Outcomes of interest were primary AVF failure and primary and secondary patency at 1 and 2 years. 7,011 citations were screened and 46 articles met eligibility criteria (62 unique cohorts; n = 12,383). The rate of primary failure was 23% (95% CI, 18%-28%; 37 cohorts; 7,393 AVFs). When primary failures were included, the primary patency rate was 60% (95% CI, 56%-64%; 13 studies; 21 cohorts; 4,111 AVFs) at 1 year and 51% (95% CI, 44%-58%; 7 studies; 12 cohorts; 2,694 AVFs) at 2 years. The secondary patency rate was 71% (95% CI, 64%-78%; 10 studies; 11 cohorts; 3,558 AVFs) at 1 year and 64% (95% CI, 56%-73%; 6 studies; 11 cohorts; 1,939 AVFs) at 2 years. In metaregression, there was a significant decrease in primary patency rate in studies that started recruitment in more recent years. Low quality of studies, variable clinical settings, and variable definitions of primary AVF failure. In recent years, AVFs had a high rate of primary failure and low to moderate primary and secondary patency rates. Consideration of these outcomes is required when choosing a patient's preferred access type. Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial.

Laura Dember, Gerald J Beck, Michael Allon … (2008)

The arteriovenous fistula is the preferred type of vascular access for hemodialysis because of lower thrombosis and infection rates and lower health care expenditures compared with synthetic grafts or central venous catheters. Early failure of fistulas due to thrombosis or inadequate maturation is a barrier to increasing the prevalence of fistulas among patients treated with hemodialysis. Small, inconclusive trials have suggested that antiplatelet agents may reduce thrombosis of new fistulas. To determine whether clopidogrel reduces early failure of hemodialysis fistulas. Randomized, double-blind, placebo-controlled trial conducted at 9 US centers composed of academic and community nephrology practices in 2003-2007. Eight hundred seventy-seven participants with end-stage renal disease or advanced chronic kidney disease were followed up until 150 to 180 days after fistula creation or 30 days after initiation of dialysis, whichever occurred later. Participants were randomly assigned to receive clopidogrel (300-mg loading dose followed by daily dose of 75 mg; n = 441) or placebo (n = 436) for 6 weeks starting within 1 day after fistula creation. The primary outcome was fistula thrombosis, determined by physical examination at 6 weeks. The secondary outcome was failure of the fistula to become suitable for dialysis. Suitability was defined as use of the fistula at a dialysis machine blood pump rate of 300 mL/min or more during 8 of 12 dialysis sessions. Enrollment was stopped after 877 participants were randomized based on a stopping rule for intervention efficacy. Fistula thrombosis occurred in 53 (12.2%) participants assigned to clopidogrel compared with 84 (19.5%) participants assigned to placebo (relative risk, 0.63; 95% confidence interval, 0.46-0.97; P = .018). Failure to attain suitability for dialysis did not differ between the clopidogrel and placebo groups (61.8% vs 59.5%, respectively; relative risk, 1.05; 95% confidence interval, 0.94-1.17; P = .40). Clopidogrel reduces the frequency of early thrombosis of new arteriovenous fistulas but does not increase the proportion of fistulas that become suitable for dialysis. Trial Registration clinicaltrials.gov Identifier: NCT00067119.

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Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I).

Hemal Shah, E Lok, Louise Moist … (2006)

Fistulas are the preferred permanent hemodialysis vascular access but a significant obstacle to increasing their prevalence is the fistula's high "failure to mature" (FTM) rate. This study aimed to (1) identify preoperative clinical characteristics that are predictive of fistula FTM and (2) use these predictive factors to develop and validate a scoring system to stratify the patient's risk for FTM. From a derivation set of 422 patients who had a first fistula created, a prediction rule was created using multivariate stepwise logistic regression. The model was internally validated using split-half cross-validation and bootstrapping techniques. A simple scoring system was derived and externally validated on 445 different, prospective patients who received a new fistula at five large North American dialysis centers. The clinical predictors that were associated with FTM were aged > or =65 yr (odds ratio [OR] 2.23; 95% confidence interval [CI] 1.25 to 3.96), peripheral vascular disease (OR 2.97; 95% CI 1.34 to 6.57), coronary artery disease (OR 2.83; 95% CI 1.60 to 5.00), and white race (OR 0.43; 95% CI 0.24 to 0.75). The resulting scoring system, which was externally validated in 445 patients, had four risk categories for fistula FTM: low (24%), moderate (34%), high (50%), and very high (69%; trend P < 0.0001). A preoperative, clinical prediction rule to determine fistulas that are likely to fail maturation was created and rigorously validated. It was found to be simple and easily reproducible and applied to predictive risk categories. These categories predicted risk of FTM to be 24, 34, 50, and 69% and are dependent on age, coronary artery disease, peripheral vascular disease, and race. The clinical utility of these risk categories in increasing rates of permanent accesses requires further clinical evaluation.

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Contributors

Carlo Lomonte: carlolomonte@libero.it

Journal

Journal ID (nlm-ta): J Nephrol

Journal ID (iso-abbrev): J. Nephrol

Title: Journal of Nephrology

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1121-8428

ISSN (Electronic): 1724-6059

Publication date (Electronic): 16 January 2016

Publication date PMC-release: 16 January 2016

Publication date (Print): 2016

Volume: 29

Issue: 2

Pages: 175-184

Affiliations

[1 ]U.O.C. di Nefrologia e Dialisi, Ente Ecclesiastico Ospedale “F.Miulli”, 70021 Acquaviva delle Fonti, Italy

[2 ]ISNI 0000 0004 1760 7116, GRID grid.415044.0, , Struttura Complessa a Direzione Universitaria di Nefrologia e Dialisi, Ospedale Giovanni Bosco, ; Turin, Italy

[3 ]GRID grid.416325.7, , Unità di Nefrologia e Dialisi, Ospedale San Carlo, ; Milan, Italy

[4 ]ISNI 0000 0001 0941 3192, GRID grid.8142.f, Dipartimento di Scienze Chirurgiche, Policlinico Gemelli, , Università Cattolica Sacro Cuore, ; Rome, Italy

[5 ]ISNI 0000 0004 1757 3729, GRID grid.5395.a, Dipartimento di Medicina, , Università di Pisa, ; Pisa, Italy

[6 ]ISNI 0000 0004 1762 600X, GRID grid.263145.7, , Scuola Superiore Sant’Anna, ; Pisa, Italy

[7 ]GRID grid.416240.5, , Unità di Nefrologia e Dialisi, Ospedale Santo Spirito, ; Pescara, Italy

[8 ]U.O.C. di Nefrologia e Dialisi, Ospedale Annunziata, Cosenza, Italy

[9 ]Unità di Nefrologia e Dialisi, A.O. Cannizzaro, Catania, Italy

[10 ]Unità di Nefrologia e Dialisi, Ospedale San Gavino Monreale, Cagliari, Italy

[11 ]U.O.C. di Nefrologia e Dialisi, Ospedale Santa Caterina Novella, Galatina, Italy

[12 ]Unità di Nefrologia e Dialisi, Ospedale di Carpi, Carpi, Italy

[13 ]ISNI 0000 0004 1754 977X, GRID grid.418378.1, , Unità di Nefrologia IRCCS, Fondazione Salvatore Maugeri, ; Pavia, Italy

Article

Publisher ID: 263

DOI: 10.1007/s40620-016-0263-z

PMC ID: 5429362

PubMed ID: 26780568

SO-VID: 5f0f51e8-34a2-4732-811a-fdf3f93ba720

History

Date received : 24 October 2015

Date accepted : 4 January 2016

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Keywords: vascular access,elderly,arteriovenous fistula,arteriovenous graft,central venous catheter

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Keywords: vascular access, elderly, arteriovenous fistula, arteriovenous graft, central venous catheter

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology

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Abstract

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Vascular Biology

Most cited references 54

Patency rates of the arteriovenous fistula for hemodialysis: a systematic review and meta-analysis.

Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial.

Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I).

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