Institutional Experience With Dialysis Access In Octo- And Nonagenarians
Michael David Sgroi, MD, Theodore Hart, MD, Manuel Garcia-Toca, MD.
Stanford University, Stanford, CA, USA.
OBJECTIVES: The national clinical guidelines recommend permanent hemodialysis (HD) access in ESRD patients, however, the optimal type of HD access in the elderly is controversial and also often multifactorial (catheter dependence, comorbidities, life expectancy). With the aging population, this will become even more controversial in the octo- and nonagenarians. The purpose of this study is to evaluate the clinical outcomes in elderly patients receiving initial HD access after the age of 80. Methods: This was a single institutional retrospective review of a prospectively kept dataset from 2015-2019 identifying all patients ≥ 80 years old at time of their initial dialysis access. Catheter dependence, primary failure, primary and secondary patency rates, and survival after starting dialysis were all evaluated. Univariate, chi-square, and log rank were used in statistical analysis. Results: 26 patients with 29 access procedures were performed on patients ≥ 80 years old at the time dialysis was initiated. Majority of patients were females (18 vs 8), history of HTN (100%) and DM (69%), and received a fistula instead of a graft (20 AVF vs 9 AVG). 17/26 (27%) followed the “fistula first” recommendation. There were 8 primary failures (27.4%), all of which were fistulas (z=2.23, p=0.023). Primary patency rates were not statistically different on survival analysis between AVF and AVG (p=0.138) or between location (proximal or distal) of access on the arm (p=0.192). Secondary patency rates were statistically significant in favor of fistulas compared to grafts (p=0.002). There was a 23% mortality rate for the total patient population in the study. Of those that expired, only 1/6 (16%) lived more than 1 year. Conclusion: Following the KDOQI guidelines for “right access in the right patient”, it is recommended that due to a high failure rate of distal AVF, proximal AVF or AVG should be used in the octo- and nonagenarian population. Because of the high mortality rate in this patient population, we recommend that a functional access is most important, even if it compromises long term patency.
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