Vascular Access in the Elderly: Does One Size Fit All?

of year 1. Younger (70–79 years) patients were more likely to convert to a non-CVC access as compared to those ≥ 80 years old. After adjustment of several factors, this difference between the 2 age groups persisted with greatest significance in the European subpopulation. Furthermore, patients who were maintained on CVC as their primary vascular access had a higher risk of death compared to those who converted from CVC to AV graft (AVG) or AV fistula (AVF). The authors concluded that elderly patients who commenced HD with a CVC should be converted to a non-CVC access as soon as possible after taking into account their individual clinical risk assessment [2] . The present study extended the emerging body of published literature describing the association between CVC use and higher mortality rate even in the elderly subgroups. Pastan et al. [3] demonstrated that in a cohort of 7,497 patients, the proportion of deaths among those dialyzed with CVC was 3.2% compared to non-CVC at less than 1.2%. Similarly, Bradbury et al. [4] studied incident US hemodialysis patients in Dialysis Outcomes and Practice Patterns Study and observed that conversion of CVC access to an AVF or AVG resulted in an adjusted mortality hazard ratio (HR) of 0.69, while conversion from permanent access to a catheter was associated with an adjusted mortality HR of 1.81. They also comment on the finding that most patients who converted were young, had more than 1 pre-dialysis permanent vascular access placement, and were less likely to have coronary, cerebrovascular, neurologic and peripheral vascular disease. Given the major advances in dialysis practices and technology, the feasibility of offering renal replacement therapy to increasingly more challenging and complex patients is now possible. The elderly patient population that requires renal replacement is rapidly becoming the fastest growing subgroup of all patients with end-stage renal disease (ESRD) [1] . Although most consensus guidelines advocate the use of permanent vascular access for all patients with ESRD, given the limited life expectancy coupled with a relative high rate of primary malfunction, a pragmatic use of central venous catheters (CVCs) may be considered in the elderly. Raimann et al. [2] , in this issue of American Journal of Nephrology present new data to assess important outcomes with relation to CVC vs. non-CVC in the elderly dialysis population ( ≥ 70 years of age) using the MONDO study infrastructure. This study specifically examined incident hemodialysis patients older than 70 years of age from the United States, Europe, Asia Pacific, and Latin America. The main aim of the study was to access the factors associated with conversion from CVC to non-CVC access and to ascertain an association between vascular access type and mortality. The cohort included 14,966 patients primarily from Europe and equally distributed among the 3 remaining geographical areas. CVC prevalence was noted to range from 32 to 69% and decreased in all regions after the first year of dialysis. North America had the highest prevalence of CVC by the end of the first year, while Asia Pacific showed the largest decrease in CVC prevalence at the end Published online: May 17, 2017 Nephrology American Journal of