1. For Old or Young Dialysis Patients, AV Fistulas Remain Pure Gold Andrew R. Forauer, MD Michael Bazylewicz, BS Kristine A. Pattin, BS Interventional Radiology Dartmouth-Hitchcock Medical Center Lebanon, NH

2. Scope of the problem End-stage kidney disease effects hundreds of thousands of U.S. patients Approximately 400,000 require hemodialysis 20 % of those on dialysis are age 75 or older That’s 1 out of 5 patients !

4. When your kidneys don’t work Kidneys filter the blood & remove harmful substances When they don’t work properly, the toxins accumulate, & patients become ill They will require : –an artificial form of blood filtering (=DIALYSIS) –kidney transplant

5. Dialysis 101 This requires removing blood, filtering it, and returning it the patient

6. Dialysis 101 This filtering can be accomplished by creating a connection between an artery & a vein, typically in the arm. Termed an ARTERIOVENOUS (AV) access The preferred method uses the patient’s own veins to create this connection (=an AV fistula)

7. Connection of the vein to the artery The flow of blood is indicated by the arrows (  ) from the artery, into the fistula & back to the heart. artery Fistula (vein) Left upper arm AV fistula

8. Unfortunately, narrowings develop in these AV fistulas over time Reducing blood flow through them Making dialysis less efficient Requires a medical procedure to correct Interventional Radiologists can identify these narrowings, position a balloon catheter, & dilate them (Angioplasty)

9. Misconception: The elderly patient does not do well when they require dialysis Why wouldn’t the way we provide dialysis be the same for younger vs. older patients? The elderly may have more chronic medical conditions & be receiving more medications But do these factors effect the patient’s AV access ?

10. Goals Does balloon dilation (angioplasty) of dialysis fistulas in elderly patients work the same, better, or worse compared to younger patients ? Are the patency rates (how long these fistulas remained open) in older patients to a younger patients the same ?

11. Comparing the two groups Patients aged 75 yrs & older Younger patients (age 40 – 60 yrs) Number of patients 3836 Average age (years) 80.052.9 Time on dialysis (days) 120360

12. Co-existing medical conditions Patients aged 75 yrs & older Younger patients (age 40 – 60 yrs) Diabetes 1724 High blood pressure 3027 Heart disease or atherosclerosis 2815 Heart function (% EF) 52%63%

13. Our Findings… Heart or vascular disease, the time spent on dialysis & medications had no influence on two important aspects: 1. how long the access stayed open 2. response to angioplasty to keep them open

14. How well did angioplasty work in keeping the access open ? Older patients (75 years & older): –200.2 days (6.7 months) Patients age 40 – 60 years: –211.5 days (7 months) No significant difference

15. Summary Our results support: – creating AV fistulas for dialysis in older patients; this is the preferred route for treatment – the key role Interventional Radiology plays in keeping them open and functioning properly Older patient age alone should not be viewed as limiting the patient’s access options