Frailty Screening For Determination of Hemodialysis Access Placement.

Choosing the right hemodialysis vascular access for frail patients remains difficult as the patient's preferences and the likelihood of access function and survival must be considered. We hypothesize that patients identified prior to arteriovenous (AV) access as frail by the PRISMA-7 score may have worse outcomes, indicating that fistula creation may not be the most clinically beneficial option and it would be in the best interest of the patient to receive either AV graft placement or dialysis through a percutaneous catheter. Our pilot study aims to determine if an association exists between patient frailty as defined by PRISMA-7 and newly created AV fistula and graft access outcomes. This was a single institutional prospective cohort study of patients undergoing new arteriovenous fistula (AVF) or graft (AVG) intervention from April 2021-May 2023. Patients were assessed using the PRISMA-7 frailty questionnaire before their AV access surgery. Patients were grouped by frailty score and score groups were examined for trends. Univariable analysis was performed for baseline differences between frail and non-frail patients. Failure to achieve maturation, postoperative infection and 180-day mortality difference was also investigated for frail versus non-frail patients. Univariable analysis was performed for non-maturation utilizing standard co-morbidities, arterial and venous diameters and frailty. Multivariable binary logistic regression was performed for the outcome of non-maturation utilizing frailty as one of the variables in conjunction with the univariable risks associated with non-maturation. A total of 40 patients undergoing new AV access placement were investigated, amongst whom 53% were designated as frail (PRISMA-7 score > 3). When comparing the frail and non-frail new AV access groups, the access (AVF and AVG combined) failed in 48% (10/21) of the frail patients, but only failed in 5% (1/19) of the non-frail patients 1 (p-value=0.012). When distinguishing between AV access types, AVF creations followed the overall trend with 60% (9/15) of AVF access sites in frail patients failing to mature when compared to non-frail patients who all had fistulas that matured to use (p-value=0.049). Surgical site infection was absent in all frail patients and present in 5% (1/19) of non-frail patients. Both 30 day and 60-day readmission was higher in the frail group compared to the non-frail group. 180-day mortality was present in 5% (1/21) of frail patients and absent in non-frail patients. Multivariable analysis revealed that both frailty (aOR 10.19 (1.20-82.25), P=0.033) and younger age (aOR 0.953 (0.923-0.983), P=.002) both had significant association with non-maturation. Power analysis revealed a power statistic of 0.898 indicating a probability of type 2 error of 10.02% with P=0.002. Hosmer-Lemeshow goodness of fit for the logistic regression had 75% overall accuracy for the model. Patient frailty is significantly associated with an increased incidence of AV access failure to mature.

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Copyright © 2023. Published by Elsevier Inc.