Reduced Cardiovascular Mortality Associated with Early Vascular Access Placement in Elderly Patients with Chronic Kidney Disease

Abstract

Background: Elderly patients with cardiovascular comorbidities are more likely to die before progressing to the need for undergoing hemodialysis; so deferring their predialysis vascular access (VA) surgery has been suggested. However, recent declines in cardiovascular mortality in the US population may have changed this consideration. We assessed whether there has been a parallel decrease in cardiovascular comorbidity in elderly chronic kidney disease (CKD) patients undergoing predialysis 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 predialysis VA creation from 2004 to 2009, divided them into 3 time cohorts (2004-2005, 2006-2007 and 2008-2009), 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 (from 66.5 to 59.7%, p < 0.005), heart failure (from 47.0 to 35.8%, p < 0.005), and myocardial infarction (from 6.5 to 3.3%, p < 0.001) from 2004 to 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 2004-2005 to 2008-2009 (HR 0.83, 95% CI 0.69-0.99; p = 0.04). Conclusion: In the context of a changing population from 2004 to 2009, a progressive decrease in cardiovascular comorbidities in elderly CKD patients undergoing predialysis 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 as to which elderly patients should undergo predialysis access surgery.