Vascular access for hemodialysis in older adults: a "patient first" approach.

In their landmark 1996 paper in JAMA, Hirth and colleagues reported that most patients in the United States with permanent vascular access were undergoing dialysis via a prosthetic graft rather than an autogenous fistula, despite known higher rates of infection and thrombosis associated with grafts.1 These authors also reported large regional differences in rates of graft use—ranging from 23% of patients with a permanent access in New England to 85% in the East South Central census region—that were not explained by variation in patient characteristics. These observations served as a wake-up call to the renal community, which responded with a series of initiatives to increase fistula use.2 In 1997, the Kidney Disease Outcomes Quality Initiative (KDOQI) published clinical practice guidelines for hemodialysis vascular access that strongly favored the use of fistulas over grafts. In 1998, the Health Care Financing Administration (now Centers for Medicare and Medicaid Services [CMS]) developed clinical performance measures for vascular access that included target fistula and catheter rates. In 2003, CMS partnered with the ESRD networks to implement the Fistula First initiative, a continuous quality improvement initiative intended to translate KDOQI guidelines into clinical practice. Collectively, these efforts have dramatically reshaped patterns of permanent access use in the United States. As a result, most patients with permanent access now undergo dialysis via an autogenous fistula.3 More recently, Fistula First has turned its attention toward reducing catheter use because it has become clear that policies to promote fistula use have not had the intended effect of reducing catheter reliance.3–6 Despite the success of these initiatives in reducing rates of graft use among patients of all ages, some authors have questioned the appropriateness of a “fistulafirst” approach in older adults.7,8 Because the theoretical advantages of fistulas over grafts do not accrue immediately, there is concern that patients with more limited life expectancy may not survive long enough to reap the benefits of having a fistula.9,10 Although grafts require more procedures to maintain patency, fistulas require more procedures to establish patency, with the result that overall patency may not differ substantially between the two forms of permanent access.11,12 This may be an especially important consideration in older adults because of their more limited life expectancy and increased risk of failed fistula maturation.9,10,13 In this issue of JASN, DeSilva and colleagues provide new information relevant to this dialogue.14 These authors describe survival among patients age 67 years and older who initiated long-term dialysis from 2005 to 2008 as a function of the type of vascular access first placed. In contrast to several prior studies reporting higher mortality rates in patients with a graft versus those with a fistula at the time of initiation, mortality rates for members of this cohort whose first access was a graft were similar to those for patients whose first access was a fistula. This was especially true in patients age 80 years and older, among whommortality did not significantly differ by type of first permanent access placed. As described in other studies, mortality rates among patients with catheters at onset of dialysis were much higher than for patients who had received a graft or a fistula, and this was true for all age groups. Overall, 43% of patients who had received a fistula as their initial form of permanent access initiated dialysis with a catheter compared with 25% of thosewho had received a graft. These findings add to a growing body of work questioning the wisdom of a “fistula first” approach inolder adults and arguing for greaterflexibility in choice of hemodialysis access.7–10,15,16 A limitation of policies intended to optimize vascular access for hemodialysis in this country has been a failure to take into account the complexities and challenges of the illness experience of individual patients with CKD. Strategies focusing on preferred and least preferred forms of vascular access fail to recognize that the relative benefits and harms of each form of access are critically dependent on the characteristics, circumstances, prognosis, preferences, and goals of individual patients.9,10,15,16 Because of heterogeneity in life expectancy, health status, health priorities, and illness experiences, no one approach to vascular access—whether “graft first,” “fistula first,” or “catheter last”—can be expected to meet the needs of all older adults with advanced kidney disease.7,9 Further, the traditional outcomes examined in studies of vascular access, such as survival, infection, hospitalization, and costs, may not be those that matter the most to individual patients. A qualitative study conducted among 13 Canadian hemodialysis patients who had elected to Published online ahead of print. Publication date available at www.jasn.org.