- Describe your topic.
- In elderly patients (> 70 years of age) undergoing hemodialysis, which type of vascular access (arteriovenous fistula vs. arteriovenous graft vs. catheter) results in better outcomes with respect to patency, infection, and mortality?
- Describe why this topic is important.
- The number of elderly patients (aged ≥75 years) with end-stage renal disease (ESRD) who require renal replacement therapy is rapidly increasing worldwide. Since 2000, the adjusted rate of incident dialysis in patients aged ≥75 years in the USA has increased by 12.2%; this group now represents the fastest growing segment of the ESRD population. Recently, there has been a strong effort among nephrologists to maximize placement of arteriovenous fistulas (AVF) in dialysis patients. The Fistula First Initiative and the KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines explicitly recommend AVF as the vascular access of choice in most hemodialysis patients due to superior outcomes. However, there is concern about whether general guidelines also apply to the elderly population. Opponents of “fistula first” note that vascular access planning in the elderly is different from that in younger patients, and the Fistula First Initiative may not be the preferred approach for older patients due to reduced life expectancy and conflicting results after surgery.
- Tell us why you are suggesting this topic.
- Determining an optimal vascular access for the elderly ESRD patient is challenging and dependent on multiple factors. Important considerations are life expectancy, complications from each vascular access type, patient preference, and the overall quality of life of the patient. While a ‘‘patient first’’ approach has been advocated within the context of the Fistula First Initiative, patient individualization may be of greater importance in the elderly. Evidence quality is limited because there are no randomized controlled trials and almost all studies are retrospective cohorts. Though some studies have large sample sizes, selection bias is an important factor that significantly limits the quality of data. In addition, most studies use an “incident dialysis access” analysis approach that does not account for changes in vascular access methods over time. The overall quality of the body of evidence is low. Though the Fistula First Initiative and the KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines explicitly recommend AVF as the vascular access of choice in most hemodialysis patients due to their superior outcomes, the benefits of this recommendation are less clear in the elderly. As the number of elderly patients requiring hemodialysis increases, clinicians and policy makers are in need of guidance to provide high quality care.
- Target Date.
- Describe what you are doing currently and what you are hoping will change because of a new evidence report.
- I am employed by a large health maintenance organization (Kaiser Permanente). My role is to conduct evidence reviews at the request of our clinicians. Our clinicians have expressed the need for guidance in this area. An analysis of available evidence would allow them to provide high quality care that is safe and effective in this growing population.
- How will you or your group use the information from a new evidence report?
- We will use the new evidence report to provide high quality care that is safe and effective in this growing population.
- How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?
- We would share this information with our very large group of physicians (vascular surgeons, nephrologists). A new evidence review could positively impact the health of 1000s of patients.
- Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?
- Yes, I am an employee of Kaiser Permanente. Guidance on this topic would allow us to directly apply information to the patients treated at our organization.
- Information About You: (optional)
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- Provide a description of your role or perspective.
- Evidence-based Medicine Researcher
- If you are you making a suggestion on behalf of an organization, please state the name of the organization.
- Kaiser Permanente
- Please tell us how you heard about the Effective Health Care Program.
- Subsriber to reports
