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Nephrol Dial Transplant. 2019 Oct 1;34(10):1636-1643. doi: 10.1093/ndt/gfy319.

Should a fistula first policy be revisited in elderly haemodialysis patients?

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Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy.
Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
Manchester Academy of Health Sciences Centre (MAHSC) & NIHR Devices for Dignity MedTech Co-operative, Manchester, UK.
Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
Unité INSERM 1026, Université de Bordeaux, Bordeaux, France.
Nephrology Clinic, Dialysis and Renal Transplant Center, C.I. PARHON University Hospital, Iasi, Romania.
Grigori T. Popa University of Medicine, Iasi, Romania.
UCL Centre for Nephrology, Royal Free Hospital, Division of Medicine, University College, London, UK.
Renal Unit, King's College Hospital, London, UK.
Otto Loewi Research Center, Medical University of Graz, Austria.
Department of Internal Medicine, Division of Nephrology, University Hospital Maastricht, Maastricht, The Netherlands.


Life-sustaining haemodialysis requires a durable vascular access (VA) to the circulatory system. The ideal permanent VA must provide longevity for use with minimal complication rate and supply sufficient blood flow to deliver the prescribed dialysis dosage. Arteriovenous fistulas (AVFs) have been endorsed by many professional societies as the VA of choice. However, the high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and arterial hypertension in elderly people, usually make VA creation more difficult in the elderly. Many of these patients may have an insufficient vasculature for AVF maturation. Furthermore, many AVFs created prior to the initiation of haemodialysis may never be used due to the competing risk of death before dialysis is required. As such, an arteriovenous graft and, in some cases, a central venous catheter, become a valid alternative form of VA. Consequently, there are multiple decision points that require careful reflection before an AVF is placed in the elderly. The traditional metrics of access patency, failure and infection are now being seen in a broader context that includes procedure burden, quality of life, patient preferences, morbidity, mortality and cost. This article of the European Dialysis (EUDIAL) Working Group of ERA-EDTA critically reviews the current evidence on VA in elderly haemodialysis patients and concludes that a pragmatic patient-centred approach is mandatory, thus considering the possibility that the AVF first approach should not be an absolute.


arteriovenous fistula; arteriovenous graft; central venous catheter; elderly; haemodialysis; vascular access


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