In Practice
Pursuing Permanent Hemodialysis Vascular Access in Patients With a Poor Prognosis: Juxtaposing Potential Benefit and Harm

https://doi.org/10.1053/j.ajkd.2012.07.020Get rights and content

For patients with end-stage renal disease requiring hemodialysis, the native arteriovenous fistula remains the gold standard of vascular access, with tunneled cuffed central venous catheters reserved for temporary use or as a last resort in patients for whom a permanent vascular access is not possible. It is expected that most patients receiving hemodialysis will be suitable for arteriovenous fistula placement, with suitable patients defined as those: (1) for whom long-term dialysis is expected to confer benefit, (2) with vascular anatomy amenable to arteriovenous fistula placement, and (3) with progressive irreversible kidney failure who are more likely to require dialysis than to die before reaching dialysis dependence. The present article reviews considerations for vascular access decision making, focusing on older patients and those with a poor prognosis, weighing the risks and benefits of arteriovenous fistulas, arteriovenous grafts, and central venous catheters and emphasizing that in the process of vascular access decision making for such patients, medical and ethical obligations to avoid central venous catheters must be balanced by the obligation to do no 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.

References (63)

  • M. Allon et al.

    Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients

    Kidney Int

    (2001)
  • Y. Iwashima et al.

    Effects of the creation of arteriovenous fistula for hemodialysis on cardiac function and natriuretic peptide levels in CRF

    Am J Kidney Dis

    (2002)
  • H.C. Rayner et al.

    Creation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study

    Kidney Int

    (2003)
  • A.M. O'Hare et al.

    When to refer patients with chronic kidney disease for vascular access surgery: should age be a consideration?

    Kidney Int

    (2007)
  • A.H. Moss et al.

    Utility of the “surprise” question to identify dialysis patients with high mortality

    Clin J Am Soc Nephrol

    (2008)
  • D.A. Karnofsky et al.

    The Clinical Evaluation of Chemotherapeutic Agents in CancerEvaluation of Chemotherapeutic Agents

  • L.M. Cohen et al.

    Predicting six-month mortality for patients who are on maintenance hemodialysis

    Clin J Am Soc Nephrol

    (2010)
  • S.Z. Fadem
  • C.E. Lok et al.

    Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I)

    J Am Soc Nephrol

    (2006)
  • Fistula First Breakthrough Initiative

  • J. Ethier et al.

    Vascular access use and outcomes: an international perspective from the Dialysis Outcomes and Practice Patterns Study

    Nephrol Dial Transplant

    (2008)
  • R.N. Foley et al.

    Hemodialysis access at initiation in the United States. 2005 to 2007: still “Catheter First.”

    Hemodialysis Int

    (2009)
  • J.B. Wish

    Vascular access for dialysis in the United States: progress, hurdles, controversies, and the future

    Semin Dial

    (2010)
  • R. Rehman et al.

    Ethical and legal obligation to avoid long-term tunneled catheter access

    Clin J Am Soc Nephrol

    (2009)
  • C. Smith et al.

    Choosing not to dialyse: evaluation of planned non-dialytic management in a cohort of patients with end-stage renal failure

    Nephron Clin Pract

    (2003)
  • I. Dasgupta et al.

    In good conscience—safely withholding dialysis in the elderly

    Semin Dial

    (2009)
  • R.C. Carson et al.

    Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?

    Clin J Am Soc Nephrol

    (2009)
  • C.V. Wong et al.

    Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis

    Ren Fail

    (2007)
  • T. Ellam et al.

    Conservatively managed patients with stage 5 chronic kidney disease—outcomes from a single center experience

    QJM

    (2009)
  • F.E. Murtagh et al.

    Dialysis or not?A comparative survival study of patients over 75 years with chronic kidney disease stage 5

    Nephrol Dial Transplant

    (2007)
  • T.M. Kurella et al.

    Functional status of elderly adults before and after initiation of dialysis

    N Engl J Med

    (2009)
  • Cited by (11)

    • When to initiate dialysis for end-stage kidney disease: evidence and challenges

      2018, Medical Journal of Australia
      Citation 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 Therapy
    • Surgical Approach to Hemodialysis Access

      2016, Seminars in Interventional Radiology
    View all citing articles on Scopus

    Originally published online September 20, 2012.

    View full text