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Clin J Am Soc Nephrol. 2015 Oct 7;10(10):1791-8. doi: 10.2215/CJN.09040914. Epub 2015 Aug 7.

Early Failure of Dialysis Access among the Elderly in the Era of Fistula First.

Author information

1
Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, karen.woo@surgery.usc.edu.
2
School of Pharmacy, and Sol Price School of Public Policy, University of Southern California, Los Angeles, California.
3
Sol Price School of Public Policy, University of Southern California, Los Angeles, California.

Abstract

BACKGROUND AND OBJECTIVES:

Recent evidence indicates that fistula maturation and patency may be compromised in the elderly dialysis population compared with younger patients. The objective of this study was to characterize the short-term outcomes of arteriovenous fistulas and arteriovenous grafts for hemodialysis access in the Medicare population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:

This was a retrospective cohort study performed using Medicare Part A and B claims data from 2006 through 2011. The study population included 16,464 dialysis-dependent patients age ≥66 years undergoing arteriovenous fistula and arteriovenous graft creation. The primary outcome measure was incidence of repeat fistula/graft creation and tunneled catheter placements in the 12 months after arteriovenous fistula and graft creation.

RESULTS:

In the 12 months postindex fistula/graft, the mortality in the fistula group was 28.2% versus 29.9% in the graft group (P=0.03). A repeat fistula/graft creation was required in 26.9% of patients in the fistula group and 16.7% in the graft group (P<0.001). There was no significant difference in the proportion of patients who required a tunneled hemodialysis catheter in the 12 months after an index fistula creation (fistula 28.4% versus graft 27.3%, P=0.19). In the index fistula group, 44.4% of patients required a repeat fistula/graft creation and/or a tunneled catheter, compared with 33.7% in the graft group (P<0.001). At 365 days after the index fistula/graft, the repeat fistula/graft/catheter-free survival was 39.7% in the fistula group versus 46.0% in the graft group (P<0.001). Index fistula was associated with a higher risk of loss of repeat fistula/graft/catheter-free survival with an odds ratio of 1.19 (95% confidence interval, 1.13 to 1.24).

CONCLUSIONS:

Fistulas were associated with a somewhat lower mortality than grafts in the first 12 months after creation. However, the incidence of repeat fistula/graft creation and tunneled catheter placement is substantially higher in the first 12 months after fistula creation compared with grafts. One-year repeat fistula/graft/catheter-free survival is lower after fistula creation than grafts.

KEYWORDS:

ESRD; Medicare claims; arteriovenous shunt; geriatric nephrology; surgical failure

PMID:
26254301
PMCID:
PMC4594075
DOI:
10.2215/CJN.09040914
[Indexed for MEDLINE]
Free PMC Article

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