Ιωάννης Γ .Γριβέας , MD,PhD

Το δίλημμα της έναρξης ή διακοπής της εξωσωματικής κάθαρσης σε εύθραυστους ηλικιωμένους νεφροπαθείς

Dialysis can be a life-extending treatmentfor patients of all ages,but one year mortality for >75 years olddialysis starts in the US was 41%, ascompared to 28% for the those aged 65-74and 17% for patients aged 45-64

In addition to limited life expectancy,many older adults experience functionaldecline and increased episodes

of hospitalization after starting dialysis

Vandecasteele SJ, Kurella-Tamura MA. Patient-centered vision of care for ESRD: dialysis as a bridging treatment or as a final destination? J Am Soc Nephrol. 2014;25:1647–51.

Berger JR, Hedayati S. Renal replacement therapy in the elderly population. Clin J Am Soc Nephrol. 2012;7:1039–46.

.

o Over time the dialysis population shiftedfromA younger, healthier cohort to an older, moremedically complex group of patients.

o Between 1980 and 2012patients aged 65-74 initiating dialysisincreased by 47%while those aged ≥ 75 (older adults) increasedby 300%

Vandecasteele SJ, Kurella-Tamura MA. Patient-centered vision of care for ESRD: dialysis as a bridging treatment or as a final destination? J Am Soc Nephrol. 2014;25:1647–51.

Berger JR, Hedayati S. Renal replacement therapy in the elderly population. Clin J Am Soc Nephrol. 2012;7:1039–46.

Diabetic kidney disease is the singlemost common cause of renal failure andaccounts for 24% of patients withchronic kidney disease (CKD) in the UK

CKD is often associated with othermedical conditions, such as heartdisease and diabetes.There is an increased risk of mortalityin patients who have advanced CKD.

Your

Slide

TitleThe lack of specific symptoms can result in peoplewith CKD not being diagnosed or diagnosed whenthey have advanced stages of CKD.Approximately one third of patients who have theadvanced stages of kidney disease have a latereferral to kidney services which is associated with

an increase in mortality and morbidity

Quality of life

eGFR <30ml/min/1.73 m2, AKI

alb /cr r>300 mg/gm.orsustained decline in renal function of >5 ml/min/1.73 m2/year

GFR-Proteinuria

Between 1996 and 2009 the percentof “early”, at eGFR >10 ml/min/1.73 m2,US dialysisstarts in older adults increased from 25% to

62%

Failed to demonstrate a survival benefit for “early start” dialysis

Recent guidelines, which recommenddeferring dialysis until patients have lowlevels ofeGFR (≤6 ml/min/1.73 m2)

unless a patient is symptomatic at a higher

e GFR level

•Rosansky SJ, Clark WF. Has the yearly increase in the renal replacement therapy population ended? J Am Soc Nephrol. 2013;24:1367–70 •Rosansky SJ, Cancarini G, Clark WF, Eggers P, Germaine M, Glassock R, et al. Dialysis initiation: what’s the rush? SeminDial. 2013;26:650–7. •Nesrallah GE, Mustafa RA, William FC Bass A, Barnieh L, Hemmelgarn BR, Klarenbach S, et al. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ. 2014;186:112–7

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2B u i l d b e t t e r p r e s e n t a t i o n s i n l e s s t i m e

3-Month Mortality in Incident Elderly ESRD Patients

Estimate the risk of early death (at 3 months) in elderly

patients starting dialysisGender

AgeModel has not been validated for patients < 75 years of age75-8485-89≥90Mobility?Walks without helpNeeds assistance with walkingTotally dependent

Congestive Heart Failure?

Dysrhythmia

Active Cancer?

Severe Behavioral

Disorder?,

Serum Albumin?<25 g/L25-29.9 g/L30-34.9 g/L≥35 g/L

Peripheral Vascular Disease?Use the Leriche classification

Grade I - AsymptomaticGrade II - Intermittent ClaudicationGrade III - Pain/Paresthesia at restGrade IV - Trophic disorder or necrosis with ulcer or gangrene

https://qxmd.com/calculate/calculator_286/3-month-mortality-in-incident-elderly-esrd-patients

Calculate by QxMDMedical Calculator

Calculate by QxMD 17+Medical CalculatorQxMD Medical Software

56,790,500Write here your big numbers

Write here your big numbers

3

In an acute care setting, delaying dialysis may not bean option for a category of patients

somatic protein storesin acutely ill patients

“early”(absent a conventional or life threatening indication)dialysis initiation in the acute setting is not supported by available studies

repeated joint decision discussions

Clinical Considerations

Although the majorityof older adults withadvanced CKD lose renalfunction slowly, 51% ofan older adult (mean age77) US dialysispopulation had an episodeof AKI in the six monthsprior to starting dialysisand 65% of patientsin this age group starteddialysis whilehospitalized

Patientswho initiate dialysisduring emergentsituations are likelyto have a higher initialeGFR, a higher level ofcomorbidity (includingepisodes of congestiveheart failure) and thusmay experience higherninety-day mortalityrates

a syndrome precipitated by and oftenattributed to changes in cellular or molecularpathways that lead to multiple alterations inhomeostatic responsiveness

The most widely accepted clinical definition is that used by Fried et al. , is defined as the presence of three of five criteria: Unintentional weight loss, self-reported exhaustion,slow gait speed, weakness (measured using a hand-grip), andlow physical activity.

Geriatric Giants in Dialysis

4

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marketing and by marketers.

BIG TITLE

5B u i l d b e t t e r p r e s e n t a t i o n s i n l e s s t i m e

PalliativeDialysis75-80 years

(1995-199)

75-80

years

(1990-

1994)

6,3 months

2,73 years

3,19 years

8,3 months

Balancing Benefit and Burdenwho would be a good dialysis candidate and who would do poorlyattempts to define a subpopulation of elderly patients whowould not do well on dialysis have been largely unsuccessful.

Age, functional status, mobility, and comorbidity burden arepredictive of survival but do not explain sufficient variability toallow the development of a criterion score that can be used toselect patients for dialysis.Individualized assessment seems to be optimal

The use of PD in elderly patients may be controversial.

Advocates for PD still champion personal independenceas the sole largest benefit of the treatment .

Extrapolation ofthe data showing an increased mortality risk would likely shortenlife only by a few weeks to months in contrast to a potentiallyimproved quality of life

Differences between thetwo dialysis modalities,in terms of functionaland cognitive burden,independence,and satisfaction with life,are lacking but mayinfluence physicianpractice.

Initiatives to promote carewithin residential and nursinghome settings and to promoteindependent living with PDmay become increasinglyimportant in modality decision-

making

USACenter based HD 94%

Home HD 1%

PD 5 %

BRASILLife expectancy in the countryincreased by 25.4 years - from 48 to73.4 - between 1960 and 2010.It is believed that by 2025 Brazil’s

elderly population will rank sixth inthe world, with 32 million peopleaged 60 and above.

UK the mean age

of patients on dialysis is 65

Home HD 1%

PD 13 %

NEW ZEALAND

Center based HD 52%

Home HD 8%

PD 39 %

AUSTRALIAHome HD 4%

PD 20 %

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You can find me at:

www.athens-nephrology.gr

giannisgriv@hotmail.com

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1B u i l d b e t t e r p r e s e n t a t i o n s i n l e s s t i m e

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a syndrome precipitated by and oftenattributed to changes in cellular or molecularpathways that lead to multiple alterations inhomeostatic responsiveness

The most widely accepted clinical definition is that used by Fried et al. , is defined as the presence of three of five criteria: Unintentional weight loss, self-reported exhaustion,slow gait speed, weakness (measured using a hand-grip), andlow physical activity.

Geriatric Giants in Dialysis

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PalliativeDialysis75-80 years

(1995-199)

75-80

years

(1990-

1994)

6,3 months

2,73 years

3,19 years

8,3 months

Balancing Benefit and Burdenwho would be a good dialysis candidate and who would do poorlyattempts to define a subpopulation of elderly patients whowould not do well on dialysis have been largely unsuccessful.

Age, functional status, mobility, and comorbidity burden arepredictive of survival but do not explain sufficient variability toallow the development of a criterion score that can be used toselect patients for dialysis.Individualized assessment seems to be optimal

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derives value from also can

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You can find me at:

www.athens-nephrology.gr

giannisgriv@hotmail.com

Any questions?

Thanks!

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Maximal Non Dialytic Conservative Management

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Intensive CKD approach in a multidisciplinary clinic staffed by dietitians,social workers, and other support personnel.Patients receive the same care as they do in earlier CKD stages, withemphasis on supportive, symptomatic care.

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