Medical Technology and Practice Patterns Institute, Bethesda, MD; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.
Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD.
Am J Kidney Dis. 2020 Oct;76(4):480-489.e1. doi: 10.1053/j.ajkd.2020.02.449. Epub 2020 Jul 9.
RATIONALE & OBJECTIVE: The current clinical guidelines for vascular access do not have specific recommendations for older hemodialysis patients. Our study aimed to determine the association of age with arteriovenous fistula (AVF) placement, maturation, and primary and secondary patency loss among older hemodialysis recipients.
Retrospective cohort study.
SETTING & PARTICIPANTS: A US national cohort of incident hemodialysis patients 67 years or older (N = 43,851) assembled from the US Renal Data System.
Age at dialysis initiation.
AVF placement, maturation, primary patency loss, and abandonment.
Cause-specific and subdistribution proportional hazards models were used to examine the association of age and AVF outcomes, with kidney transplantation, peritoneal dialysis, and death treated as competing events. Age cutoff was identified by restricted cubic splines. We compared crude and inverse probability-weighted cumulative incidence functions using Gray's test.
As compared with those aged 67-<77 years, patients 77 years or older had significantly lower probabilities of AVF placement (adjusted cause-specific HR [cHR], 0.96 [95% CI, 0.92-0.99]; adjusted subdistribution HR [sHR], 0.92 [95% CI, 0.89-0.95]; Gray's test P < 0.001) and maturation (adjusted cHR, 0.95 [95% CI, 0.91-0.99]; adjusted sHR, 0.93 [95% CI, 0.90-0.97]; P < 0.001). However, age was not associated with AVF primary (adjusted cHR, 1.05 [95% CI, 1.00-1.11]; adjusted sHR, 1.04 [95% CI, 0.99-1.09]; P = 0.09) or secondary (adjusted cHR, 1.06 [95% CI, 0.94-1.20]; adjusted sHR, 1.05 [95% CI, 0.93-1.18]; P = 0.4) patency loss.
Reliance on administrative claims to ascertain AVF outcomes.
The likelihood of AVF maturation is an important consideration for vascular access planning. Age alone should not be the basis for excluding older dialysis patients from AVF creation because maintenance of fistula patency was not reduced with older age despite a modest reduction in fistula maturation.
目前血管通路的临床指南并没有针对老年血液透析患者的具体建议。本研究旨在确定年龄与老年血液透析患者动静脉瘘（AVF）置管、成熟以及原发性和继发性通畅损失之间的关系。
回顾性队列研究。
这项来自美国肾脏数据系统的美国全国性老年血液透析患者队列研究（n=43851），纳入年龄≥67 岁的新血液透析患者。
透析开始时的年龄。
AVF 置管、成熟、原发性通畅损失和废弃。
使用因果特定和亚分布比例风险模型来检验年龄与 AVF 结局之间的关系，将肾移植、腹膜透析和死亡视为竞争事件。通过限制性立方样条确定年龄切点。我们使用 Gray 检验比较了未经校正和反向概率加权累积发生率函数。
与年龄 67-<77 岁的患者相比，77 岁或以上的患者 AVF 置管的概率显著降低（校正后的因果特定风险比[cHR]，0.96[95%CI，0.92-0.99]；校正后的亚分布风险比[sHR]，0.92[95%CI，0.89-0.95]；Gray 检验 P<0.001）和成熟的概率也显著降低（校正后的因果特定风险比[cHR]，0.95[95%CI，0.91-0.99]；校正后的亚分布风险比[sHR]，0.93[95%CI，0.90-0.97]；P<0.001）。然而，年龄与 AVF 原发性（校正后的因果特定风险比[cHR]，1.05[95%CI，1.00-1.11]；校正后的亚分布风险比[sHR]，1.04[95%CI，0.99-1.09]；P=0.09）或继发性（校正后的因果特定风险比[cHR]，1.06[95%CI，0.94-1.20]；校正后的亚分布风险比[sHR]，1.05[95%CI，0.93-1.18]；P=0.4）通畅损失无关。
依赖行政索赔来确定 AVF 结局。
AVF 成熟的可能性是血管通路规划的一个重要考虑因素。单纯的年龄不应成为将老年透析患者排除在 AVF 建立之外的依据，因为尽管 AVF 成熟率略有下降，但随着年龄的增加，瘘管通畅率并没有降低。
