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The aging of the world population is accompanied by an increase in the incidence of chronic end-stage renal disease (ESRD) in elderly patients. The ideal vascular access (VA) type for elderly hemodialysis (HD) patients remains debatable. The debate as to whether “fistula first” in elderly patients arises from lower maturation rates, longer maturation times and emerging data suggesting lack of a survival benefit in arteriovenous fistula (AVF) compared to central venous catheter (CVC). Otherwise, among incident HD patients ˃80 years (yrs) observed that arteriovenous graft fistula (AVG) and CVC was associated with similar mortality as compared with initial AVF use in this population. Also demonstrated that longer duration of CVC was associated with increasingly higher mortality in this population. The fact that there is no consensus on this topic makes it important for continuing study.
The aim of this study was to examine patterns of VA at admission and 3 months after admission among a cohort of incident elderly HD patients stratified by age. Additionally, we investigated whether the type of VA used at 3 months after admission was associated with differential survival in this population.
We conducted a single-center retrospective cohort study in HD incident patients between January 2017 and July 2023 in CASMU Hemodialysis Center, Montevideo, Uruguay. All patients ≥ 70 yrs in HD at least 3 months were included. The primary outcome was all-cause mortality. Patients were categorized in 2 age groups, between 70 and 80 yrs and older than 80 yrs. According to age groups baseline characteristics were analyzed and compared using t-student test for quantitative variables and chi-square test for qualitative variables. Survival outcomes were analyzed using Kaplan-Meier survival curves and Cox′s proportional hazards models adjusted for age, sex, diabetes, and CVC.P-value <0.05 was considered significant. Statistical analysis was performed using SPSS v20.
One hundred and sixty-five patients were recruited, 111(67.3%) men and 74 (44.8%) diabetics. At admission, most of them had CVC (84.2%), 3 months after admission 53.3% had CVC and 46.7% AVF or AVG. The last vascular access was CVC in 42.7%. 83% of the patients between 70-79 yrs had at least one AVF/AVG, while in ≥ 80 yrs only 59% had at least one AVF or AVG (p<0.05). The main cause of hospitalization of these patients was not related to vascular access (27.1 ± 29.5 days), without differences among age groups (p=NS). 54.5% of the patients had 2 or more CVC during time on HD (Table 1). The mean and medians for survival time in patients with AVF 3 months after admission was significantly superior with respect to patients with CVC, 46.8 months versus 38.9 months respectively (p<0.05) (Figure 1). In Cox regression model CVC has a 65% major risk of death (HR= 1.65, p<0.05) (Table 2).
Conclusions
The use of CVC in HD population is increasing worldwide. There is no evidence to support that elderly patients cannot have an AVF. Even in elderly patients the overall survival was superior in those with AVF or AVG respect to those with CVC.