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American Journal of Kidney Diseases

The New Age of Vascular Access: Choosing the Right Access for the Right Reason in Older Hemodialysis Patients

  • Crystal Farrington
    Affiliations
    Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
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  • Timmy C. Lee
    Correspondence
    Address for Correspondence: Timmy C. Lee, MD, MSPH, Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Zeigler Research Bldg 524, 1720 2nd Ave S, Birmingham, AL 35294-0007.
    Affiliations
    Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL

    Division of Nephrology, Veterans Affairs Medical Center, Birmingham, AL
    Search for articles by this author
      Related article, p. 480
      According to the 2018 US Renal Data System (USRDS) report, 88% of the 125,000 incident patients with end-stage kidney disease (ESKD) in the United States select hemodialysis as their kidney replacement modality of choice.
      • Saran R.
      • Robinson B.
      • Abbott K.C.
      • et al.
      US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
      Among these patients, 80% use a central venous catheter (CVC) at hemodialysis initiation.
      • Saran R.
      • Robinson B.
      • Abbott K.C.
      • et al.
      US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
      Most patients who initiate hemodialysis with a CVC will subsequently undergo placement of a permanent vascular access: either an arteriovenous fistula (AVF) or an arteriovenous graft (AVG).
      Vascular access guidelines in the United States, such as those put forward in 2006 by KDOQI (Kidney Disease Outcomes Quality Initiative from the National Kidney Foundation),
      KDOQI Vascular Access Work Group
      Clinical practice guidelines for vascular access.
      have uniformly promoted the use of AVFs over AVGs for permanent vascular access in hemodialysis patients. These recommendations are based on observational studies suggesting that AVFs require fewer interventions to maintain primary patency and have better long-term survival (ie, fewer abandonments) compared with AVGs.
      • Allon M.
      • Robbin M.L.
      Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions.
      However, elderly hemodialysis patients may be less likely to experience the benefits of AVF placement due to higher AVF maturation failure rates
      • Lok C.E.
      • Allon M.
      • Moist L.
      • Oliver M.J.
      • Shah H.
      • Zimmerman D.
      Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I).
      ,
      • Richardson 2nd, A.I.
      • Leake A.
      • Schmieder G.C.
      • et al.
      Should fistulas really be first in the elderly patient?.
      and shorter life expectancy.
      • Richardson 2nd, A.I.
      • Leake A.
      • Schmieder G.C.
      • et al.
      Should fistulas really be first in the elderly patient?.
      ,
      • O'Hare A.M.
      • Bertenthal D.
      • Walter L.C.
      • et al.
      When to refer patients with chronic kidney disease for vascular access surgery: should age be a consideration?.
      With these issues in mind, in a report published in this issue of AJKD, Qian et al
      • Qian J.Z.
      • McAdams-Demarco M.
      • Ng D.K.
      • Lau B.
      Arteriovenous fistula placement, maturation, and patency loss in older patients inititating hemodialysis.
      analyzed data from the USRDS registry in a large retrospective observational study evaluating the association of age with AVF placement, successful AVF use (AVF maturation), loss of primary patency, and AVF abandonment (secondary patency). Competing events such as kidney transplantation, transfer to peritoneal dialysis, and death were also considered when examining the association between age and AVF outcomes. The study found that patients 77 years and older were less likely to have AVF placement and successful use compared with patients aged 67 to 76 years. However, among patients in either age group with successful AVF maturation, there was no difference in time to loss of primary patency or AVF abandonment. The findings from this study have important implications for vascular access choice in elderly patients because the question frequently arises as to whether we should even consider placing AVFs in this group.
      The elderly population is one of the fastest growing segments of the hemodialysis population. Among incident hemodialysis patients in the United States, 52% are 65 years or older.
      • Saran R.
      • Robinson B.
      • Abbott K.C.
      • et al.
      US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
      However, achieving successful vascular access outcomes remains a significant challenge in most older hemodialysis patients. Two observational studies from Lok et al
      • Lok C.E.
      • Allon M.
      • Moist L.
      • Oliver M.J.
      • Shah H.
      • Zimmerman D.
      Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I).
      ,
      • Lok C.E.
      • Oliver M.J.
      • Su J.
      • Bhola C.
      • Hannigan N.
      • Jassal S.V.
      Arteriovenous fistula outcomes in the era of the elderly dialysis population.
      reported that elderly patients (defined as ≥67 years in both studies) are at greatest risk for unsuccessful AVF use. A meta-analysis of 13 observational studies encompassing a total of 1,844 patients demonstrated higher rates of unsuccessful radiocephalic AVF use in older (>65 years) compared with younger patients (≤65 years).
      • Lazarides M.K.
      • Georgiadis G.S.
      • Antoniou G.A.
      • Staramos D.N.
      A meta-analysis of dialysis access outcome in elderly patients.
      In contrast, other studies have shown similar AVF maturation and patency between younger and older patients. Weale et al
      • Weale A.R.
      • Bevis P.
      • Neary W.D.
      • et al.
      Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly.
      reported that age did not affect successful AVF use, loss of primary patency, or AVF abandonment in either radiocephalic or brachiocephalic AVFs when patients were analyzed in stratified age groups of younger than 65, 65 to 79, and 80 years and older. Collectively, most available studies suggest that AVF outcomes are worse in older versus younger patients. However, all these studies are limited by observational design, small sample sizes, and nonuniform definitions of AVF maturation and patency.
      The study by Qian et al is unique in that it focuses on the specific subset of older patients (aged ≥67 years) who initiate hemodialysis with a CVC and subsequently have an AVF placed. Of the cohort of patients initiating hemodialysis with a CVC, only 34% had AVF placement within 6 months. Within this latter group, only 50% had successful AVF use in the ensuing 6 months.
      • Qian J.Z.
      • McAdams-Demarco M.
      • Ng D.K.
      • Lau B.
      Arteriovenous fistula placement, maturation, and patency loss in older patients inititating hemodialysis.
      Furthermore, the older group of patients (≥77 years) had lower probability of AVF placement and maturation and were more likely to experience a competing event than those in the 67- to 76-year age group.
      • Qian J.Z.
      • McAdams-Demarco M.
      • Ng D.K.
      • Lau B.
      Arteriovenous fistula placement, maturation, and patency loss in older patients inititating hemodialysis.
      The results of this study highlight the need for an individualized approach to vascular access planning in older hemodialysis patients.
      The newly published 2019 KDOQI vascular access guideline update emphasizes a patient-centered approach to vascular access, which includes the development of an ESKD Life-Plan.
      • Lok C.E.
      • Huber T.S.
      • Lee T.
      • et al.
      KDOQI clinical practice guideline for vascular access: 2019 update.
      The ESKD Life-Plan is a strategy for kidney care that begins in the period before the onset of kidney failure. It addresses key issues such as kidney replacement modality options and vascular access use across a patient’s anticipated lifespan, paying special attention to overall medical condition, current and future life goals, patient preferences, social support, functional status, and logistics related to kidney replacement therapy.
      • Lok C.E.
      • Huber T.S.
      • Lee T.
      • et al.
      KDOQI clinical practice guideline for vascular access: 2019 update.
      ,
      • Woo K.
      • Lok C.E.
      New insights into dialysis vascular access: what is the optimal vascular access type and timing of access creation in CKD and dialysis patients?.
      The ultimate goal of the ESKD Life-Plan is to achieve the “right access, for the right patient, at the right time, for the right reason.”
      • Inston N.
      • Lok C.E.
      Improving precision in prediction: using kidney failure risk equations as a potential adjunct to vascular access planning.
      This objective is especially critical for the older population with advanced kidney disease.
      Within the context of the ESKD Life-Plan, a vascular access plan should be tailored to the needs of the individual patient. Important factors to consider in developing a plan for vascular access include: (1) predicted life expectancy and prognosis, (2) baseline functional status, (3) patient preference, (4) underlying vascular biology, (5) probability of successful AVF maturation or assisted maturation, (6) likelihood of subsequent maintenance interventions, and (7) impact of vascular access choice on quality of life for patients and their families. Although the current study by Qian et al shows that in patients 77 years and older, AVF placement and successful use are lower compared with patients aged 67 to 76 years, it also demonstrates that even the oldest hemodialysis patients should not be immediately excluded from consideration for AVF placement. Older hemodialysis patients with successful AVF maturation have rates of primary AVF patency loss or access abandonment comparable to those in their younger counterparts.
      • Qian J.Z.
      • McAdams-Demarco M.
      • Ng D.K.
      • Lau B.
      Arteriovenous fistula placement, maturation, and patency loss in older patients inititating hemodialysis.
      This finding emphasizes that with a thoughtful ESKD Life-Plan that includes an appropriate vascular access plan, strategic AVF placement in some older hemodialysis patients could result in good short- and long-term AVF outcomes.
      What are the take-home messages for those of us caring for older patients with advanced kidney disease (Fig 1)? First, it is essential to develop an ESKD Life-Plan, which will assist in formulating a vascular access plan customized to the individual patient. This initial step, in which the patient, patient’s family, and health care team convene to discuss whether to initiate dialysis, is critical to the next steps. The mortality rate in older hemodialysis patients is high
      • Kurella M.
      • Covinsky K.E.
      • Collins A.J.
      • Chertow G.M.
      Octogenarians and nonagenarians starting dialysis in the United States.
      ,
      • Joly D.
      • Anglicheau D.
      • Alberti C.
      • et al.
      Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes.
      so supportive care pathways are an appropriate alternative to dialysis. If supportive care is chosen, the focus should be on preserving the patient’s quality of life and advance care planning.
      • Murtagh F.E.
      • Marsh J.E.
      • Donohoe P.
      • Ekbal N.J.
      • Sheerin N.S.
      • Harris F.E.
      Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5.
      Figure thumbnail gr1
      Figure 1Decision-making process for older patients with advanced chronic kidney disease (CKD). In this group, development of an End-Stage Kidney Disease (ESKD) Life-Plan is critical to assist in formulating a vascular access plan customized to the individual patient and developing a plan for patients who elect not to pursue kidney replacement therapies.
      Second, if an older patient with kidney failure elects to pursue dialysis, the next step is selection of the ideal modality of kidney replacement therapy. Recent data from the USRDS
      • Saran R.
      • Robinson B.
      • Abbott K.C.
      • et al.
      US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
      show that 89% and 94% of elderly patients aged 65 to 74 and 75 years or older, respectively, choose hemodialysis over peritoneal dialysis and will therefore need to develop a workable vascular access plan.
      Third, although the current study by Qian et al focuses on AVFs, it is reasonable to consider placing either an AVF or an AVG in older hemodialysis patients.
      To this effect, some recent publications also using USRDS data demonstrate that older hemodialysis patients may not derive benefit from placement of an AVF versus an AVG due to higher comorbid conditions and shorter survival in this population. Lee et al
      • Lee T.
      • Thamer M.
      • Zhang Y.
      • Zhang Q.
      • Allon M.
      Outcomes of elderly patients after predialysis vascular access creation.
      reported that among older patients with an access placed before initiating dialysis, those with AVGs as opposed to AVFs were more likely to initiate hemodialysis with a permanent access rather than a CVC. In another recent study by Lee et al
      • Lee T.
      • Qian J.
      • Thamer M.
      • Allon M.
      Tradeoffs in vascular access selection in elderly patients initiating hemodialysis with a catheter.
      examining older patients who initiated hemodialysis with a CVC and no prior vascular access, patients who underwent subsequent AVG placement had higher rates of successful vascular access use, fewer interventions to promote initial successful use, and reduced CVC dependence compared with those who received AVFs. Thus, selective AVG placement in the older population can serve an important CVC-sparing function. Although long-term CVC use was discouraged by the previous KDOQI vascular access guideline,
      KDOQI Vascular Access Work Group
      Clinical practice guidelines for vascular access.
      the newer guideline
      • Lok C.E.
      • Huber T.S.
      • Lee T.
      • et al.
      KDOQI clinical practice guideline for vascular access: 2019 update.
      recognizes that CVCs may be an appropriate vascular access type under certain circumstances, such as in an older hemodialysis patient with limited life expectancy or those with poor vascular access sites and high likelihood of permanent vascular access failure.
      In summary, the fundamental question of whether AVFs should be placed in older hemodialysis patients, and in which ones, has no single universal answer. In keeping with this idea, the new KDOQI vascular access guideline appropriately permits a more individualized approach to vascular access, moving away from prioritizing AVFs in all hemodialysis patients to instead prioritizing each patient’s needs, preferences, and goals for vascular access in accordance with their individual ESKD Life-Plan.
      • Lok C.E.
      • Huber T.S.
      • Lee T.
      • et al.
      KDOQI clinical practice guideline for vascular access: 2019 update.
      This paradigm shift is particularly relevant in the older hemodialysis population. In some circumstances, an older hemodialysis patient may be a reasonable candidate for AVF placement if it fits the patient’s ESKD Life-Plan. As the study by Qian et al shows, a patient should not be excluded from consideration for an AVF simply due to age. This conclusion is consistent with the ultimate goal of the new KDOQI guideline recommendations: to support actions that best provide “a reliable dialysis vascular access and complication-free access to deliver prescribed dialysis, and is concurrently suitable for a patient’s needs and individual circumstances.”
      • Lok C.E.
      • Huber T.S.
      • Lee T.
      • et al.
      KDOQI clinical practice guideline for vascular access: 2019 update.
      (p S17)

      Article Information

      Authors’ Full Names and Academic Degrees

      Crystal Farrington, DO, and Timmy C. Lee, MD, MSPH.

      Support

      Dr Lee is supported by grant 2R44 DK109789-03 from the National Institute of Diabetes and Digestive and Kidney Diseases , 1R01HL139692-03 from the National Heart, Lung, and Blood Institute , and grant 1I01BX003387-04 from a Veterans Affairs Merit Award.

      Financial Disclosure

      Dr Lee is a consultant for Proteon Therapeutics, Merck, and Boston Scientific. Dr Farrington declares that she has no relevant financial interests.

      Other Disclosures

      Dr Lee was a member of the 2019 KDOQI Vascular Access Guideline Work Group.

      Peer Review

      Received March 28, 2020, in response to an invitation from the journal. Accepted March 30, 2020 after editorial review by an Associate Editor and a Deputy Editor.

      References

        • Saran R.
        • Robinson B.
        • Abbott K.C.
        • et al.
        US Renal Data System 2018 Annual Data Report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2019; 73: A7-A8
        • KDOQI Vascular Access Work Group
        Clinical practice guidelines for vascular access.
        Am J Kidney Dis. 2006; 48: S176-S273
        • Allon M.
        • Robbin M.L.
        Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions.
        Kidney Int. 2002; 62: 1109-1124
        • Lok C.E.
        • Allon M.
        • Moist L.
        • Oliver M.J.
        • Shah H.
        • Zimmerman D.
        Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I).
        J Am Soc Nephrol. 2006; 17: 3204-3212
        • Richardson 2nd, A.I.
        • Leake A.
        • Schmieder G.C.
        • et al.
        Should fistulas really be first in the elderly patient?.
        J Vasc Access. 2009; 10: 199-202
        • O'Hare A.M.
        • Bertenthal D.
        • Walter L.C.
        • et al.
        When to refer patients with chronic kidney disease for vascular access surgery: should age be a consideration?.
        Kidney Int. 2007; 71: 555-561
        • Qian J.Z.
        • McAdams-Demarco M.
        • Ng D.K.
        • Lau B.
        Arteriovenous fistula placement, maturation, and patency loss in older patients inititating hemodialysis.
        Am J Kidney Dis. 2020; 76: 480-489.e1
        • Lok C.E.
        • Oliver M.J.
        • Su J.
        • Bhola C.
        • Hannigan N.
        • Jassal S.V.
        Arteriovenous fistula outcomes in the era of the elderly dialysis population.
        Kidney Int. 2005; 67: 2462-2469
        • Lazarides M.K.
        • Georgiadis G.S.
        • Antoniou G.A.
        • Staramos D.N.
        A meta-analysis of dialysis access outcome in elderly patients.
        J Vasc Surg. 2007; 45: 420-426
        • Weale A.R.
        • Bevis P.
        • Neary W.D.
        • et al.
        Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly.
        J Vasc Surg. 2008; 47: 144-150
        • Lok C.E.
        • Huber T.S.
        • Lee T.
        • et al.
        KDOQI clinical practice guideline for vascular access: 2019 update.
        Am J Kidney Dis. 2020; 75: S1-S164
        • Woo K.
        • Lok C.E.
        New insights into dialysis vascular access: what is the optimal vascular access type and timing of access creation in CKD and dialysis patients?.
        Clin J Am Soc Nephrol. 2016; 11: 1487-1494
        • Inston N.
        • Lok C.E.
        Improving precision in prediction: using kidney failure risk equations as a potential adjunct to vascular access planning.
        J Vasc Access. 2018; 20: 95-97
        • Kurella M.
        • Covinsky K.E.
        • Collins A.J.
        • Chertow G.M.
        Octogenarians and nonagenarians starting dialysis in the United States.
        Ann Intern Med. 2007; 146: 177-183
        • Joly 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: 1012-1021
        • Murtagh F.E.
        • Marsh J.E.
        • Donohoe P.
        • Ekbal N.J.
        • Sheerin N.S.
        • Harris F.E.
        Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5.
        Nephrol Dial Transplant. 2007; 22: 1955-1962
        • Lee T.
        • Thamer M.
        • Zhang Y.
        • Zhang Q.
        • Allon M.
        Outcomes of elderly patients after predialysis vascular access creation.
        J Am Soc Nephrol. 2015; 26: 3133-3140
        • Lee T.
        • Qian J.
        • Thamer M.
        • Allon M.
        Tradeoffs in vascular access selection in elderly patients initiating hemodialysis with a catheter.
        Am J Kidney Dis. 2018; 72: 509-518

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