Background: The prior "Fistula First" practice has moved towards to an individualized end-stage kidney disease life-plan approach (1). In today's aging society the number of elderly patients requiring hemodialysis is booming. Choosing the optimal vascular access for a patient with limited life-expectancy and increased frailty can be a challenge. The literature reports conflicting data on the benefit of creating a fistula in octogenarians. The aim of this national audit was to evaluate patient survival after fistula placement and fistula outcome in men and women at age ≥80 years.

This observational retrospective study analysed prospectively collected data retrieved from the national Swedish Renal Registry, were all unites performing fistula are encompassed (3) Cumulative incidence plots were used to display survival of patient and fistula outcome separated by sex. A Cox proportional Hazard regression model was used to study the effect of age for different fistula types (forearm, upper-arm, and arteriovenous graft fistulas (AVG)) on reintervention and abandonment.

Between 2011-2017 were 6020 fistulas registered in the Swedish Renal Registry. Some 675 (11%) were placed in octogenerians (women 30%). Forearm fistulas were most frequently performed n=430 (64%), followed by upper-arm fistulas n= 155 (23%) and AVG n=90 (13%). Fistula event free patient survival after one year was 33%, presented separated by sex (Figure 1). At three years, event free survival was 12% among octogenarians, as compared to 15% in patients ≤ 80 years. Assisted patency after one-and three years among surviving patients was 66% and 64 % Fistula abandonment was more prevalent in women (29 % vs 21% p=0.002) while mortality was higher in men (41% vs 36% p=0.05). (Figure 2). The association between age and interventions was only shown for forearm fistulas (1.11 (95% CI: 1.06-1.15) p<0.001) while no association was demonstrated for abandonment in any type of fistulas (Table 1).

One in three patients at age ≥80 years had an event free patient survival after one year and reinterventions were frequent. However secondary patency among survivors at three years was acceptable, two of three patients had a functioning fistula. Forearm fistulas were associated with a higher risk of interventions, why a more proximal location or AVG may be considered in this age group. Age alone should not disqualify a patient for fistula surgery. Although these results emphasise the importance of an individualized assessment, where life-expectancy, sex, quality of life related to redo procedures should be taken into account.

1. Lok, C. E., et al. (2020). "KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update." Am J Kidney Dis 75(4 Suppl 2): S1-s164. 2. Welander, G. and B. Sigvant (2021). "Validating vascular access data in the Swedish Renal Registry SRR." J Vasc Access 22(4): 629-634.