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Deprecated: Implicit conversion from float 247.2 to int loses precision in C:\Inetpub\vhosts\kidney.de\httpdocs\pget.php on line 534 Am+J+Nephrol 2016 ; 43 (5): 334-40 Nephropedia Template TP
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Reduced Cardiovascular Mortality Associated with Early Vascular Access Placement in Elderly Patients with Chronic Kidney Disease #MMPMID27166150
Lee T; Thamer M; Zhang Q; Zhang Y; Allon M
Am J Nephrol 2016[]; 43 (5): 334-40 PMID27166150show ga
Background: Elderly patients with cardiovascular comorbidities are more likely to die before progressing to needing hemodialysis, so deferring their pre-dialysis vascular access (VA) surgery has been suggested. However, recent declines in cardiovascular mortality in the U.S. population may have changed this consideration. We assessed whether there has been a parallel decrease in cardiovascular co-morbidity in elderly chronic kidney disease (CKD) patients undergoing pre-dialysis access surgery, and whether this impacted clinical outcomes after access creation and cardiovascular events after hemodialysis initiation. Methods: We identified 3,418 elderly patients undergoing pre-dialysis VA creation from 2004-2009, divided them into 3 time cohorts (2004-05, 2006-07 and 2008-09), and assessed their clinical outcomes during 2 years of follow-up. Results: There was a progressive decrease in patients with history of peripheral vascular disease (66.5 to 59.7%, p<0.005), heart failure (47.0 to 35.8%, p<0.005), and myocardial infarction (6.5 to 3.3%, p<0.001) from 2004-2009. Death before hemodialysis decreased from 17.5 to 12.6%, survival without hemodialysis increased from 14.5 to 19.0%, and hemodialysis initiation remained constant at ~68% (p<0.001). The incidence of death or cardiovascular event in the first year of hemodialysis decreased from 2004-05 to 2008-09 (HR=0.83, 95% CI, 0.69-0.99; p=0.04). Conclusion: In the context of a changing population from 2004-09, a progressive decrease in cardiovascular comorbidities in elderly CKD patients undergoing pre-dialysis VA surgery was associated with a decrease in death before hemodialysis and cardiovascular events after starting hemodialysis. These insights should be translated into more thoughtful consideration of which elderly patients should undergo pre-dialysis access surgery.