Gold standard dialysis procedure may not be so golden for elderly patients

The elderly represent the most rapidly growing group of patients on dialysis for kidney failure. Research clearly shows an arteriovenous fistula, which is created by connecting a patient's own vein and artery to form a long-lasting site through which blood can be removed and returned, is the best way to gain access to the blood for dialysis in younger individuals. Other types of access involve the use of a catheter, which does not require needle sticks, and arteriovenous grafts, which is a plastic conduit between an artery and a vein. It's currently unclear which of these is the best type of dialysis access for elderly patients.

To investigate, Ranil DeSilva, MD, Alexander Goldfarb-Rumyantzev, MD, PhD (Beth Israel Deaconess Medical Center), and their colleagues studied information from 2005 to 2008 on more than 115,000 dialysis patients over 66 years of age, 35% of whom were in their 80s and 90s.

Among the major findings over four years:

• The use of catheters was linked with more than a 74% increased risk of death in patients of any age.

• While use of an arteriovenous fistula improved survival compared with use of an arteriovenous graft in patients in their late 60s and 70s, patients in their 80s and 90s experienced similar survival rates with the two procedures.

The findings suggest that in patients who are older than 80 years, placing a graft -- which takes a much shorter time to establish and can be placed shortly before starting dialysis -- may be a reasonable alternative to a fistula. This is particularly true for those with small veins or when it is uncertain when dialysis may be needed.

"In an era using more standardized quality outcome measures, we must remain cautious about generalizing measures to our growing elderly population. In the case of our study, a strategy that is clearly superior in young individuals requiring hemodialysis for kidney failure does not appear to be the clearly superior strategy for elderly individuals," said Dr. DeSilva. "It appears that the optimal vascular access choice should be tailored to the specific patient in the elderly population," he added.

In an accompanying editorial, Ann O'Hare, MD (University of Washington, Seattle) stressed that "to deliver care that is truly centered on the patient, we may ultimately need to set aside traditional metrics focusing on universal treatment targets… in favor of new ones focusing on the extent to which the process and outcomes of access selection support the goals and preferences of individual patients."

Study co-authors include Bhanu Patibandla, MD, Yael Vin, MD, MPH, Akshita Narra MD, Varun Chawla, MD, and Robert Brown, MD.