approach to advanced kidney disease management in the elderly source: schell jo, germain mj,...

Approach to Advanced Kidney Disease Management in the Elderly

Source Schell JO Germain MJ Finkelstein FO et al An integrative approach to

advanced kidney disease in the elderly Adv Chronic Kidney Dis 201017(4)368ndash377

Introductionbull Mrs DB an 82-year-old woman with long-standing hypertension and poorly

controlled diabetes had recent weight lossbull Besides this her recent problem included worsening renal function with accelerated

declines in her glomerular filtration rate (GFR) (12 mLmin)bull For her worsening renal function she was referred to a nephrologistbull She complained of poor appetite and disinterest in community activities which

according to her was due to agingbull On examination she appeared and had mild lower extremity swellingbull Laboratory examination was suggestive of advanced renal failure with low albumin

and hemoglobinbull These kinds of patients are often referred to nephrologistsbull Chronic kidney disease (CKD) is progressively increasing due to the increase in the

geriatric age groupbull Several studies have shown that an elderly patient with CKD are more likely to have

comorbidities walking impairments and decrements in the quality of life as compared to the elderly with normal renal function

bull A major dilemma for the nephrologist treating the elderly patient such as Mrs DB is to decide whether to initiate dialysis or treat conservatively

bull In addition the nephrologist has to decide how best to attend to the patientrsquos burden of disease and suffering

Dialysis or Conservative Managementbull Elderly patients like Mrs DB represent the fastest growing segment of the dialysis

populationbull A study in the US has shown that the rate of elderly patients (gt75 years) initiating

dialysis is about 2000 per million population an increase of about 11 since the year 2000

bull The median age of patients starting dialysis has also increased from 56 years in 1986 to 644 years in 2008

bull Although the rates of dialysis initiation continue to rise in the elderly patients the survival has not markedly increased and there are often deficits in the quality of life

bull Recent studies have shown that in elderly patients the initiation of dialysis was associated with poor survival (see Fig 1) with a rapid decline in the functional status before death (see Fig 2)

bull Recent research indicates that elderly patients with advanced kidney disease have a high mortality regardless of the treatment approach (conservative treatment or dialysis)

bull The annual mortality rate of patients undergoing dialysis is approximately 23 in USA and with only about 38 surviving 5 years

bull The mortality rate in elderly dialysis patients (104869265 years) is six times higher than those in the general population

bull Elderly patients with advanced kidney disease often have comorbidities such as diabetes congestive heart failure and coronary artery disease

bull In addition most patients have poor physical functioning including disability in ambulation

bull In a study dialysis initiation was associated with a functional decline in dialysis patients that was observed to be independent of age gender race and functional status before initiation of dialysis

bull The results showed that after 12 months of dialysis 58 of patients in the cohort had died and only 13 maintained predialysis functional status

bull Several studies have shown that outcomes after hospitalization and invasive procedures are poor in patients with CKD

bull These patients are at a significant risk of sudden cardiac death and decreased survival at 6 months after hospitalization following cardiopulmonary resuscitation as compared to controls

bull This evidence shows that elderly patients with advanced kidney disease often have several associated comorbidities

bull This significantly increases the risk for invasive procedures which often negatively affects their survival and quality of life

bull Hence before aggressive management is considered the patient should be thoroughly evaluated and detailed information should be given to the patient regarding disease progression and management

Health-Related Quality of Life in the Elderlybull Elderly patients with kidney disease often have compromised health-

related quality of life (HRQOL) in a variety of HRQOL domains (physical mental or emotional)

bull The impairments are more pronounced for physical aspects as compared to mental or emotional domains

bull It has been noted that reductions in HRQOL scores are associated with decreased survival and increased risk of increased hospitalization

bull Impairments of physical aspects of HRQOL are more marked in elderly patients as compared to younger patients

bull Depression has also been observed to be prevalent in end-stage renal disease (ESRD) and dialysis patients and has been observed to worsen outcomes

bull In a prospective study the authors followed hemodialysis (HD) patients (n=98) on the basis of direct patient interviews and reported that about 25 of the patients had clinical depression

bull Of these patients about 80 had died or were hospitalized at the time of follow-up as compared to 431 of the nondepressed patients Several other studies have also shown similar results

bull This suggests the existence of a strong relationship between depression and mortality

bull As depression is potentially treatable these facts should be considered significant

bull Hence besides focusing on lsquolife-sustainingrsquo therapy such as dialysis a major concern while treating should be measures to improve the HRQOL and decrease the burden of disease and therapy

Prognostication of Kidney DiseaseA Challenge

bull Deciding the management approach in patients with advanced kidney disease can be a major challenge for the nephrologists

bull In high-risk patients it can be very difficult to decide whether the benefits of dialysis initiation outweigh the risks and even in the patients already on dialysis it is important to identify chronically debilitated patients with a poor QOL who would benefit from withdrawal from dialysis and only palliative care

bull Hence it is important that a patient is evaluated properly before initiation of dialysis and the prognosis the risk associated with treatment and mortality are explained to the patient

bull This should be a norm rather than exception as patients and the care providers desire to know information about prognosis and survival

Initiation Practices for Dialysisbull Mrs DBrsquos presentation with advanced kidney disease is a

common scenario for the nephrologist and most of these patients are often started on dialysis without adequate predialysis visits and evaluation

bull In most patients dialysis is often initiated using HD venous catheters instead of permanent access such as a native fistula

bull In a study HD patients gt67 years of age with venous catheters have a mortality rate of 415 as compared to 249 in patients with native fistula

bull In several studies these factors have been implicated as predictors of early mortality

bull Lack of adequate referral is also a factor that limits adequate management of patients with renal disease

bull In a study 603 elderly patients ge75 years were considered as late referral as compared to 429 of nonelderly patients

bull This limits the opportunity for a nephrologist to evaluate the patients adequately and to build and maintain trust

bull The mortality of elderly patients who are not adequately evaluated is high mostly due to infectious complications and hospitalizations

bull A retrospective analysis of hospitalized patients who were started on dialysis showed that the mean survival was 19 months 294 months and 52 months for patients aged gt75 years 65ndash74 years and 50ndash65 years respectively

bull Besides age-associated comorbid conditions and functional limitation were also important in predicting survival and mortality

bull Studies have shown that timely referral and planned dialysis initiation can significantly improve the quality of life and survival of these patients

bull Timely evaluation by the nephrologist needs improved referral guidelines for primary care physicians and good communication between nephrologists and referring physicians

Integrated Management of Patients with Kidney Disease

bull According to studies many patients with advanced CKD are more likely to die early after starting dialysis than with conservative management

bull The progression of kidney disease may be slower with conservative management bull This suggests that many elderly patients may survive with low GFRs and do not

need dialysisbull In these patients starting dialysis may result in the rapid decline of residual renalbull function and worsen the prognosisbull Hence an approach to maintain the residual renal function and the symptomatic

treatment may be reasonable in elderly patients with advanced CKDbull If patients such as Mrs DB are referred timely and are appropriately evaluated for

risks and decrements in their quality of life before dialysis initiation more patients will be started on other treatment plans including conservative management which will probably improve the overall prognosis of these patients

Conclusion

bull Patients like Mrs DB are not unique and therefore the highrisk elderly patients with advanced kidney disease should be evaluated optimally before dialysis is initiated

bull As a doctor the treatment approach should be patient-centered rather than the disease alone

Comprehensive Basketin Anemia Management


Introduction

Dialysis or Conservative Management

Slide 4

Slide 5

Health-Related Quality of Life in the Elderly

Slide 7

Prognostication of Kidney Disease A Challenge

Initiation Practices for Dialysis

Slide 10

Slide 11


Conclusion

Comprehensive Basket in Anemia Management

Introductionbull Mrs DB an 82-year-old woman with long-standing hypertension and poorly

controlled diabetes had recent weight lossbull Besides this her recent problem included worsening renal function with accelerated

declines in her glomerular filtration rate (GFR) (12 mLmin)bull For her worsening renal function she was referred to a nephrologistbull She complained of poor appetite and disinterest in community activities which

according to her was due to agingbull On examination she appeared and had mild lower extremity swellingbull Laboratory examination was suggestive of advanced renal failure with low albumin

and hemoglobinbull These kinds of patients are often referred to nephrologistsbull Chronic kidney disease (CKD) is progressively increasing due to the increase in the

geriatric age groupbull Several studies have shown that an elderly patient with CKD are more likely to have

comorbidities walking impairments and decrements in the quality of life as compared to the elderly with normal renal function

bull A major dilemma for the nephrologist treating the elderly patient such as Mrs DB is to decide whether to initiate dialysis or treat conservatively

bull In addition the nephrologist has to decide how best to attend to the patientrsquos burden of disease and suffering






















































Conclusion





Introduction


Slide 4

Slide 5


Slide 7



Slide 10

Slide 11


Conclusion























































Conclusion





Introduction


Slide 4

Slide 5


Slide 7



Slide 10

Slide 11


Conclusion




Introduction


Slide 4

Slide 5


Slide 7



Slide 10

Slide 11


Conclusion
