Is home hemodialysis a practical option for older people?

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.

Acute arteriovenous access failure: long-term outcomes of endovascular salvage and assessment of co-variates affecting patency.

AIMS: This study reports long-term outcomes after endovascular salvage (EVS) for acute dialysis fistula/graft dysfunction. METHODS: All patients presenting with acute fistula or graft dysfunction, excluding primary failures, referred for endovascular salvage were included in this single-centre prospective study. RESULTS: Altogether, 410 procedures were carried out in 232 patients. Overall, the incidence of thrombosis/occlusion (per patient-year) was 0.12 for fistulae and 0.9 for grafts. The anatomical success rate for EVS was 94% for fistulae and 92% for grafts. Primary patency rates for fistulae at 1, 6, 12, 24 and 36 months were 82, 64, 44, 34 and 26%, respectively, whereas secondary patency rates were 88, 84, 74, 69 and 61%, respectively. Primary patency rates for grafts at 1, 6 and 12 months were 50, 14 and 8%. The overall rate of complications was 6% with no incidence of symptomatic pulmonary embolism. In a Cox regression model, upper-arm location of fistula (HR 1.9, p = 0.04, n = 144) was associated with lower primary patency, whereas the presence of thrombosis was associated lower primary (HR 1.9, p = 0.004, n = 144) and secondary patency (HR 3.7, p < 0.001, n = 144). Aspirin therapy was associated with longer primary patency (HR 0.6, p = 0.02, n = 144) and secondary patency (HR 0.58, p = 0.08, n = 144). CONCLUSION: EVS is effective but longer-term outcomes are poor. Presence of thrombosis portends poor fistula survival and strategies for prevention need attention. Balloon maceration, our preferred declotting technique, is safe and the most cost-effective method. Aspirin therapy for patients presenting with failure of fistulae deserves further investigation.