In PracticePursuing Permanent Hemodialysis Vascular Access in Patients With a Poor Prognosis: Juxtaposing Potential Benefit and Harm
Section snippets
Case Presentation
A 78-year-old woman with estimated glomerular filtration rate (eGFR) of 39 mL/min/1.73 m2 (0.65 mL/min/1.73 m2) was referred for nephrology care. Comorbid conditions included diabetes mellitus, hypertension, coronary artery disease, ischemic cardiomyopathy, hyperlipidemia, and peripheral vascular disease. Her kidney function was stable for the next 7 months of nephrology follow-up. Over the ensuing 2 years, she sustained several myocardial infarctions, which required multiple coronary artery
Prognosis for Survival
For patients who have a poor prognosis, kidney replacement therapy may neither extend the patient's life nor prevent major deterioration of function during the patient's first year on dialysis therapy.14, 15, 16, 17, 18, 19, 20, 21 As summarized in the Renal Physicians Association's Clinical Practice Guideline for Shared Decision Making in the Appropriate Initiation and Withdrawal from Dialysis,22 a growing body of literature supports active medical management without dialysis, when
The Need for Dialysis Versus Likelihood of Death
Older patients have a high prevalence of CKD, but many older patients with CKD lose kidney function at slower rates than their younger counterparts. In addition, older patients have a lower incidence of progression to kidney failure and, as stated, often die of comorbid diseases before requiring dialysis. In one study, more than one-third of patients older than 80 years were found to have stable nonprogressive CKD, as predicted by mild proteinuria, no hypertension, and minimal cardiovascular
Surgical Amenability for and Risks With AVF Placement
Complications related to vascular access are an important cause of morbidity to patients and a major contributing factor to the high costs of dialysis care. Access-related infections are predominantly a complication of CVC use and account for the most substantial part of access-related health care expenses. The risk of thrombosis and failure to mature, as well as less common AVF complications, including steal syndrome and infection, also must be included in the risk-benefit assessment.
Case Review
The patient presented was 78 years old, had a high Charlson Comorbidity Index score (predicted 1-year survival of 50%), and had poor prognostic surgical indicator scores. We would not have been surprised had she lived only 6 months after starting dialysis therapy.1, 2, 6 Furthermore, her likelihood of AVF maturation failure was formidable7 and her AVF failed to mature by the time hemodialysis therapy was initiated. Nine months after starting dialysis therapy, she continued to dialyze with a
Conclusion and Recommendations
For patients in whom a survival benefit with dialysis is unclear, the propriety of surgical placement of a vascular access should be considered with due diligence and the decision to attempt permanent vascular access should be made in the context of age, comorbid conditions, and overall prognosis. Patients with a poor prognosis and those uncertain about long-term hemodialysis therapy but undergoing a time-limited trial of dialysis should not be subjected to AVF placement without careful
Acknowledgements
The authors acknowledge Dr Alvin “Woody” Moss for support and review of this manuscript.
Support: None.
Financial Disclosure: The authors declare that they have no relevant financial interests.
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2018, Medical Journal of AustraliaCitation Excerpt :Conventional thrice weekly haemodialysis is known to be associated with accelerated loss of residual renal function.23 Other risks associated with dialysis include infection,24 painful access procedures,25,26 high symptom burden and psychosocial impact, including depression and anxiety, all of which can negatively affect a patient’s quality of life.27 In fact, deterioration of health-related quality of life over time is observed in patients who undergo dialysis28 and, therefore, these risks should be carefully weighed against the potential benefits when deciding the timing of dialysis initiation.
The challenging surgical vascular access creation
2023, Cardiovascular Diagnosis and TherapyTreatment decisions for older adults with advanced chronic kidney disease
2017, BMC NephrologySurgical Approach to Hemodialysis Access
2016, Seminars in Interventional RadiologyVascular access for incident hemodialysis patients in Catalonia: Analysis of data from the Catalan Renal Registry (2000-2011)
2015, Journal of Vascular Access
Originally published online September 20, 2012.