Reduced Cardiovascular Mortality Associated with Early Vascular Access Placement in Elderly Patients with Chronic Kidney Disease.
Reduced Cardiovascular Mortality Associated with Early Vascular Access Placement in Elderly Patients with Chronic Kidney Disease.
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DOI：
10.1159/000446159
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发表时间：
2016
影响因子：
4.2
通讯作者：
Allon M
中科院分区：
文献类型：
--
作者：
Lee T;Thamer M;Zhang Q;Zhang Y;Allon M
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. 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. 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). 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.
