title: Hemodialysis arteriovenous fistula as first option not necessary in elderly patients.
abstract: OBJECTIVE
  Kidney Disease Outcomes Quality Initiative guidelines recommend arteriovenous fistulas as the preferred access for hemodialysis patients. However, this may not hold across all populations of patients, especially the elderly, given their comorbidities and relatively reduced life expectancy. Therefore, we investigated whether fistulas held benefit over arteriovenous grafts as hemodialysis access in elderly patients.
  
  
  METHODS
  We retrospectively searched a vascular access database to compare the outcomes for 138 fistulas and 44 grafts that were placed in elderly patients (≥75 years old) during a 4-year period at a tertiary medical center.
  
  
  RESULTS
  The primary failure rate was higher for the fistulas compared with the grafts (odds ratio, 2.89; P = .008), and more fistulas required one or more interventions before their successful use compared with grafts (31% vs 10%, respectively; P = .03). In addition, the time to catheter-free dialysis was longer for fistulas than for grafts (P < .001). However, the primary and secondary patency rates were comparable between the fistulas and grafts and between the different access locations. The all-cause mortality rates were also comparable between the fistula and graft groups.
  
  
  CONCLUSIONS
  Despite the Fistula First Initiative recommendations, grafts need not be discounted as a first-line hemodialysis access option in select elderly patients.
authors.affiliation: Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Jie
authors.initials: J
authors.lastname: Cui
authors.affiliation: Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: David
authors.initials: D
authors.lastname: Steele
authors.affiliation: Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Julia
authors.initials: J
authors.lastname: Wenger
authors.affiliation: Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Tatsuo
authors.initials: T
authors.lastname: Kawai
authors.affiliation: Department of Interventional Radiology, Chinese People's Liberation Army General Hospital, Beijing, China.
authors.forename: Fengyong
authors.initials: F
authors.lastname: Liu
authors.affiliation: Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Nahel
authors.initials: N
authors.lastname: Elias
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Watkins
authors.affiliation: Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address: zirani@mgh.harvard.edu.
authors.forename: Zubin
authors.initials: Z
authors.lastname: Irani
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000401:mortality; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D001900:Boston; D016009:Chi-Square Distribution; D015897:Comorbidity; D016208:Databases, Factual; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008017:Life Expectancy; D016015:Logistic Models; D008297:Male; D016017:Odds Ratio; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency