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Elderly patients with CKD—dilemmas in dialysis therapy and vascular access

Nature Reviews Nephrology volume 10, pages 116–122 (2014)Cite this article

Subjects

Key Points

  • Management of chronic kidney disease in elderly patients is complex

  • Planning for renal replacement therapy and dialysis vascular access requires evaluation of comorbidities and quality of life

  • Selection of the ideal vascular access for an elderly patient requires pre-operative vessel mapping and consideration of vascular biology, the patient's ability to function independently and their anticipated life expectancy

  • Ethical issues, optimal timing of vascular access creation and predicting the outcomes of various types of permanent access remain challenging

Abstract

The population of elderly patients with end-stage renal disease (ESRD) is growing rapidly worldwide. The high prevalence of comorbidities, limited life expectancy and complex quality of life issues associated with this population pose substantial challenges for clinicians in terms of clinical decision-making and providing optimal care. The first dilemma encountered in the management of an elderly patient with ESRD is deciding whether to initiate renal replacement therapy and, if so, selecting the most-suitable dialysis modality. Planning vascular access for haemodialysis is associated with additional challenges. Several clinical practice guidelines recommend an arteriovenous fistula, rather than a central venous catheter or arteriovenous graft, as the preferred access for maintenance haemodialysis therapy. However, whether this recommendation is applicable to elderly patients with ESRD and a limited life expectancy is unclear. Selection and planning of the most appropriate vascular access for an elderly patient with ESRD requires careful consideration of several factors and ultimately should lead to an improvement in the patient's quality of life.

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Figure 1: Complex decision planning process for elderly patients with ESRD.

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Authors and Affiliations

  1. Division of Nephrology, W. G. (Bill) Hefner Veterans Affairs Medical Center, 1601 Brenner Avenue, Salisbury, 28144, NC, USA

    Tushar J. Vachharajani

  2. Division of Nephrology, Kidney Clinical Research Unit, Schulich School of Medicine and Dentistry, Victoria Hospital, Canada

    Louise M. Moist

  3. Department of Vascular Surgery, Eastern Virginia Medical School, USA

    Marc H. Glickman

  4. Division of Nephrology, University of Texas Southwestern Medical Center, USA

    Miguel A. Vazquez

  5. Department of Medicine and Department of Nephrology, Monash Medical Center & Monash University, Australia

    Kevan R. Polkinghorne

  6. Division of Nephrology, Department of Medicine, Toronto General Hospital and University of Toronto, Canada

    Charmaine E. Lok

  7. Division of Nephrology, University of Alabama at Birmingham, USA.,

    Timmy C. Lee

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Contributions

T. J. Vachharajani and T. C. Lee researched data for the article, provided a substantial contribution to discussions of the content, wrote the article and reviewed and/or edited the manuscript before submission. L. M. Moist and M. A. Vazquez provided a substantial contribution to discussions of the content and reviewed and/or edited the manuscript before submission. K. R. Polkinghorne reviewed and/or edited the manuscript before submission. C. E. Lok wrote the article and reviewed and/or edited the manuscript before submission. M. H. Glickman wrote the article and provided a substantial contribution to discussions of the content.

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Correspondence to Tushar J. Vachharajani.

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Vachharajani, T., Moist, L., Glickman, M. et al. Elderly patients with CKD—dilemmas in dialysis therapy and vascular access. Nat Rev Nephrol 10, 116–122 (2014). https://doi.org/10.1038/nrneph.2013.256

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