'Fistula First' Strategy Is Not Always Best for Elderly Hemodialysis Patients

July 01, 2013

By Will Boggs, MD

NEW YORK (Reuters Health) Jul 01 - Contrary to current recommendations, creating a fistula may not be superior to placing an arteriovenous graft (AVGs) in patients over 80 who will be needing hemodialysis, according to results from the US Renal Data System (USRDS).

"Based on the results of our study, our main point was less to push more for an AVG-first strategy as the primary recommendation in the elderly but rather a push for a more patient centered approach to this elderly population," Dr. Ranil N. DeSilva from Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, told Reuters Health.

"In an era using more standardized quality outcomes measures, we must remain cautious generalizing many outcome measures to our growing elderly population," Dr. DeSilva added.

Using data from 115,425 hemodialysis patients aged 67 and older, the research team evaluated all-cause mortality based on the route of vascular access that was established predialysis.

Most patients (78.4%) had a catheter as their first predialysis vascular access. Only 18.6% had an arteriovenous fistula (AVF) created in advance, and only 3.0% had an AVG.

In the overall study population, having a catheter as the initial predialysis access was associated with 77% higher risk of mortality than having an AVF, the researchers reported online June 27 in the Journal of the American Society of Nephrology.

Mortality rates were similar overall for patients having an AVG or an AVF as the initial predialysis access. For patients aged 67-79, however, the mortality risk was 10% higher when an AVG was placed first, predialysis, compared to when an AVF was created first.

Among older patients, though, there was no significant mortality difference between receiving a graft predialysis, or having a fistula created predialysis.

"Overall, there currently exists some controversy between advocates of fistula first and catheter last," the researchers note. "We are presenting data here to support a competing strategy of AVG first in many octogenarians when individual characteristics, such as uncertain prognosis for survival, poor vasculature, or variable rate of progression to ESRD, may make this option preferable to the nephrologist."

"It is well recognized and confirmed in our study that a central venous catheter is a clearly inferior strategy with a much higher mortality than either a fistula or a graft," Dr. DeSilva explained.�"But since the elderly have the highest rate of fistula complications, including failure to mature for use, patients over 80 years old who underwent placement of a graft first did just as well as those with a fistula placed first."

And, he said, "even in those over 67 years old, a fistula first strategy was only little better."

In an editorial, Dr. Ann M. O'Hare from Veterans Affairs Puget Sound Healthcare System and the University of Washington in Seattle also advocates a "patient first" approach. She told Reuters Health by email, "I think this paper demonstrating that there are not large differences in survival among older patients who undergo graft vs. fistula placement removes from the equation undue concerns about increasing mortality risk and supports the case for greater flexibility in choice of vascular access for hemodialysis in this population."

"Ultimately, decisions about vascular access should be shared between the physician and the patient and their family based on an assessment of the expected benefits vs. harms of each form of access for an individual patient and with an understanding of what outcomes matter most to that patient (which might have nothing to do with survival, thrombosis or infection)," Dr. O'Hare said. "I believe that we should move away from rigid and universal notions of preferred forms of access, and performance measures that reinforce these notions, toward a more flexible approach that takes into account the circumstances and preferences of individual patients and that values the process of access selection."

SOURCE: http://bit.ly/18r1QA0

J Am Soc Nephrol 2013.

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