Background: Clinical practice guidelines recommend arteriovenous fistulas as the preferred form of vascular access for hemodialysis. However, some studies have suggested that older age is associated with poorer fistula outcomes.
Objective: We assessed the impact of age on the outcomes of fistula creation and access-related procedures.
Design: This was a prospective cohort study using data collected as part of the Dialysis Measurement Analysis and Reporting (DMAR) system.
Setting: Participating Canadian dialysis programs, including Southern Alberta Renal Program, Manitoba Renal Program, Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario), and The Ottawa Hospital (Ottawa, Ontario).
Patients: Incident hemodialysis patients aged 18 years and older who started dialysis between January 1, 2004, and May 31, 2012.
Measurements: The primary outcome was the proportion of all first fistula attempts that resulted in catheter-free fistula use, defined as independent use of a fistula for hemodialysis (ie, no catheter in place). Secondary outcomes included the time to catheter-free fistula use among patients with a fistula creation attempt, total number of days of catheter-free fistula use, and the proportion of a patient's hemodialysis career spent with an independently functioning fistula (ie, catheter-free fistula use).
Methods: We compared patient characteristics by age group, using t tests or Wilcoxon rank sum tests, and chi-square or Fisher exact tests, as appropriate. Logistic and fractional logistic regression were used to estimate the odds of achieving catheter-free fistula use by age group and the proportion of dialysis time spent catheter-free, respectively.
Results: A total of 1091 patients met our inclusion criteria (567 age ≥ 65; 524 age < 65). Only 57% of first fistula attempts resulted in catheter-free fistula use irrespective of age (adjusted odds ratio [OR]≥65vs<65: 1.01; P = .93). The median time from hemodialysis start to catheter-free use of the first fistula did not differ by age when grouped into fistulas attempted pre- and post-dialysis initiation. The adjusted rates of access-related procedures were comparable (incidence rate ratio [IRR]≥65vs<65: 0.95; P = .32). The median percentage of follow-up time spent catheter-free was similar and low in patients who attempted fistulas (<65 years: 19% vs ≥65 years: 21%; P = .85).
Limitations: The relatively short follow-up time may have underestimated the benefits of fistula creation and the observational study design precludes inferences about causality.
Conclusions: In our study, older patients who underwent a fistula attempt were just as likely as younger patients to achieve catheter-free fistula use, within a similar time frame, and while requiring a similar number of access procedures. However, the minority of dialysis time was spent catheter-free.
Keywords: arteriovenous fistula; central venous catheter; chronic kidney disease; hemodialysis.
© The Author(s) 2019.
Conflict of interest statement
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Timing of Fistula Creation and the Probability of Catheter-Free Use: A Cohort StudyA Clarke et al. Can J Kidney Health Dis 6, 2054358119843139. PMID 31105964.Predialysis fistula attempts were associated with a higher probability of catheter-free use and remaining catheter-free over time, and also resulted in fewer procedures c …
Outcomes of the First and Second Hemodialysis Fistula: A Cohort StudyF Kamar et al. Am J Kidney Dis 73 (1), 62-71. PMID 30122545.Outcomes of a second fistula may be inferior to outcomes of the initial fistula. First and second fistula outcomes are weakly correlated and difficult to predict based on …
Utilization, Patency, and Complications Associated With Vascular Access for Hemodialysis in the United StatesIJ Arhuidese et al. J Vasc Surg 68 (4), 1166-1174. PMID 30244924.Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using cat …
Do Central Venous Catheters Have Advantages Over Arteriovenous Fistulas or Grafts?F Quarello et al. J Nephrol 19 (3), 265-79. PMID 16874685. - ReviewCentral venous accesses have become an integral component of vascular access procedures for hemodialysis. Although the DOQI guidelines recommend that less than 10% of chr …
Vascular Access for Hemodialysis: Current Practice in VietnamLD Dinh et al. J Vasc Access 20 (1_suppl), 20-23. PMID 30596466. - ReviewA well-functioning vascular access is a mainstay to perform an efficient hemodialysis procedure, which directly affects the quality of life in hemodialysis patients. We u …
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