Clinical Outcomes in Very Elderly Patients According to Vascular Access at Hemodialysis Start

Introduction: Vascular access (VA) has a significant impact in the quality of life and survival of patients on hemodialysis (HD). The very elderly are a subgroup of patients whose incidence of renal replacement therapy is the highest. This study aimed to evaluate the impact of the VA at HD start on one­ ‑year mortality in this population. Methods: Retrospective analysis of patients aged 80 years or older who started HD between January 2014 and December 2019 at Centro Hospitalar Universitário Lisboa Norte. We excluded patients who died in the first 90 days after dialysis started. Mortality within one year of HD start was evaluated. Demographic, clinical and laboratory variables were submitted to univariate and multivariate analysis to determine predictive factors of one­ ‑year mortality after HD start. Overall survival was analyzed using Kaplan­ ‑Meier curves and the log­ ‑rank test. Results: One hundred eighty­ ‑nine patients were eligible. The mean age was 84.6 ± 3.59 years, and the majority were male (60.3%) and Caucasian (95.2%). One hundred and twenty­ ‑four patients started HD with a central venous catheter (CVC) (65.6%), 62 (32.8%) with an AVF and three patients (1.6%) with an AVG. Mortality within one year after HD started was 21.7% (n=41). One­ ‑year mortality was the highest in patients who started and remained with a CVC, compared to patients who started with a CVC and had an AVG placed, to patients who started with a CVC and had an AVF placed, to patients who started with an AVF and to patients who started with an AVG, respectively 43.2% vs 27.3% vs 21.7% vs 6.4% vs 0% (p<0.001). On the multivariate analysis, only diabetes (aHR 2.49 (1.16­ ‑5.34), p=0.020) and starting and remaining with a CVC (aHR 3.83 (1.71­ ‑8.38), p=0.001) were significant predictors of one­ ‑year mortality. Conclusion: In the very elderly, starting HD with a CVC and remaining with this VA is associated with higher mortality rather than starting with or switching to arteriovenous access.