The List: ASN KidneyGeriatric News Kidney “What Care to Watch” in 2011

CKD in the Elderly tula creation and advocate caution and take a few minutes to hear the patient’s baum, et al. Rapid decline of kid- careful consideration prior to referral perspective (http://www.youtube.com/ ney function increases cardiovas- Continued from page 11 for surgery. One option is to consider watch?v=EOciMaCyJW4). cular risk in the elderly. J Am Soc guidelines suggesting preemptive fis- delaying fistula creation for three to six Nephrol 2009. tula creation in patients planning for months while the older patient is estab- Suggested reading 5. Anderson S, Halter JB, Hazzard hemodialysis do not differentiate be- lished onto dialysis and adjusts to their 1. American Society of Nephrology WR, et al. Prediction, progression, tween the 40-year-old and 80-year-old new lifestyle. Geriatric Nephrology Curriculum and outcomes of chronic kidney patient with stage 4/5 CKD. However, The use of the CGA helps clinicians http://www.asn-online.org/educa- disease in older adults. J Am Soc Ne- older patients are at higher than nor- appreciate that the detection and man- tion_and_meetings/geriatrics/ ac- phrol 2009; 20:1199–1209. mal risk of fistula failure-to-mature; agement of CKD in elderly individu- cessed 31 Dec 2010. 6. S. V. Jassal and D. Watson. Doc, death prior to dialysis-need; and only als requires ongoing collaboration with 2. NephSAP 2011, volume 10 Geriat- don’t procrastinate...Rehabilitate, have modest survival rates after dialysis allied health and palliative care teams, ric Nephrology, January 2011. palliate, and advocate. Am J Kidney initiation. geriatricians, as well as the family and 3. Coresh J, Selvin E, Stevens LA, et Dis. 2010; 55:209-212, 2010. In the recently published ASN patient. An appreciation of the impact al. Prevalence of chronic kidney dis- geriatric nephrology curriculum Seth that renal disease has on diet, lifestyle ease in the United States. J Am Med Vanita Jassal is a staff nephrologist at the Wright and John Danzinger discuss and well-being is necessary. To this Assoc 2007; 298:2038–2047. University Health Network and associate in detail the benefits, and risks, of fis- point, it is humbling and insightful to 4. Shlipak MG, Katz R, B. Kesten- professor at the University of Toronto.

Special Considerations for Dialysis in the Elderly

By Yi-Wen Chiu and Rajnish Mehrotra

n the United States, as in many other the case for the elderly, in particular (2). ative management and renal replacement tomatic individuals with lower eGFR. developed countries, the incidence Therefore, dialysis planning can be futile therapy requires shared decision-making However, the results of the IDEAL study of treated end stage renal disease if it is to begin for every elderly patient that should involve the nephrologist, the suggest that many elderly CKD patients (ESRD)I increases with advancing age; the with eGFR <30 mL/min/1.73 m2. patient, and the patient’s family. A time- with declining renal function are likely highest rates are observed in individuals Recent studies suggest that individu- limited trial of dialysis may facilitate de- to require dialysis at higher levels of renal between the ages of 75 and 79 (Figure 1) als with significant proteinuria, or an cision-making for some patients. Patients function (8). (1). There is concern, however, that the underlying primary renal disease, or with who choose maximum conservative man- functional rehabilitation of elderly di- declining trajectory of renal function are agement or withdraw from dialysis after a Is one dialysis modality better alysis patients is often unsatisfactory and more likely to need dialysis. If these is- time-limited trial may also be appropriate than the other for elderly the gain in life expectancy with renal re- sues, along with the patient’s functional candidates for hospice care at some stage patients with ESRD? placement therapy is rather modest. This status, are factored in when deciding of their disease. The overwhelming majority of ESRD should not be surprising, because elderly which elderly patients with low eGFR patients in the United States are treated What is the optimal time to patients with ESRD have a significantly should begin preparing for dialysis, the with in-center hemodialysis; peritoneal begin dialysis therapy? greater burden of coexisting illnesses and potential futility of the process could be dialysis remains the dominant home dial- are more likely to be frail. reduced. In the United States, patients are starting ysis modality (1). Numerous observation- Unique psychosocial issues that in- dialysis therapy at progressively higher al studies have compared the outcomes of terplay with medical conditions must A role for maximum levels of eGFR; the higher the age, the patients treated with in-center hemodial- be factored in when planning for renal conservative management? greater the proportion of individuals ysis and peritoneal dialysis. These studies replacement therapy for the elderly. Con- The life expectancy of patients start- who begin dialysis at an eGFR >10 mL/ suggest that elderly patients treated with sequently, nephrologists grapple with sev- ing dialysis therapy in the United States min/1.73 m2 (1, 6). Several observational peritoneal dialysis, particularly those with eral important issues when dealing with is about one-quarter of age- and sex- studies have shown an inverse relation- diabetes mellitus and/or coexisting ill- an elderly patient with advanced chronic matched individuals without kidney dis- ship between eGFR at the start of renal nesses, have a somewhat shorter survival kidney disease (CKD): Is dialysis plan- ease, and elderly patients starting dialysis replacement therapy and the subsequent than those treated with in-center hemodi- ning appropriate for all elderly CKD risk for death, leading some to argue that patients? Does dialysis therapy improve are no exception (1). The median life ex- alysis (9). However, over the past decade it is the dialysis treatment itself that is the functional status and increase the life pectancy of dialysis patients between the in the United States, improvements in the expectancy of the frail elderly, and is there ages of 75 and 79 is 2.9 years, compared at least partly responsible for the higher outcomes of peritoneal dialysis patients a role for maximum conservative therapy? with 10.8 years for individuals in the gen- mortality in patients who start dialysis have outpaced those seen with in-center Does dialysis increase the risk of death in eral population (3). early (7). However, the same studies in- hemodialysis patients (10). Thus, in the elderly patients if started at a higher level A recent study has focused on the dicate that patients who begin dialysis most recent cohorts, the differences in of estimated glomerular filtration rate dismal outcomes of frail elderly nursing at higher levels of eGFR are much more survival seen in patients treated with ei- (eGFR)? Is one dialysis modality better home residents. An overwhelming ma- likely to be men, elderly, diabetic, and ther dialysis modality have substantially than the other for elderly patients with jority of such patients experienced con- with greater cardiovascular comorbidity narrowed and are probably not clinical ESRD? tinued functional decline and/or death (7). meaningful (11). within 12 months of starting dialysis (4). Given the lack of detail about the These findings suggest that the sur- Dialysis planning for the elderly: Studies such as this suggest that in frail clinical status of individual patients in vival studies should have little if any bear- for whom, and when? individuals with advanced CKD, starting national registries such as the U.S. Renal ing when assisting elderly patients and/ dialysis may not necessarily improve their Data System, it is unlikely that statistical or their families in selecting an appropri- One of the areas in the field of nephrology functional status and/or increase their life adjustments will account for the greater ate dialysis modality. On one hand, the with the greatest opportunity to improve expectancy. These observations have also disease burden of patients who begin di- burden of coexisting diseases, frailty, and the management of patients is the time spurred interest in considering maximum alysis at higher levels of renal function. social isolation may make in-center he- of dialysis initiation. To improve the early conservative care as one of the therapeutic Furthermore, the results of the recently modialysis a particularly attractive thera- outcomes of ESRD patients, it is often options for frail elderly patients with ad- published IDEAL study indicate that peutic option for many elderly ESRD recommended that dialysis planning be- vanced CKD in lieu of preparation for di- starting dialysis at higher levels of eGFR patients. On the other hand, the ability gin when the eGFR decreases to <30 mL/ alysis, including anemia correction with does not itself increase the risk for death to undergo dialysis at home may be per- 2 min/1.73 m . However, several epidemio- erythropoietin, loop diuretics to prevent (8). These considerations suggest that ceived by some elderly patients as the best logic studies from unselected populations volume overload, phosphate-binders to in symptomatic individuals, it is safe to method for them to maintain their inde- have shown that in patients with ad- manage itching, and potassium restric- start dialysis even if the eGFR is >10 mL/ pendence and dignity. Peritoneal dialysis vanced CKD, the risk for death is higher tion as the only dietary intervention (5). min/1.73 m2. Conversely, dialysis may has been successfully performed by oc- than the future need for dialysis; this is Choosing between maximum conserv- be safely withheld in otherwise asymp- togenarians and nonagenarians, and this February 2011 | ASN Kidney News | 13

Figure 1. Incidence of treated end stage renal disease in the Yi-Wen Chiu is affiliated with Kaohsiung disease? Clin J Am Soc Nephrol 2009; United States Medical University. Rajnish Mehrotra 4:1611–1619. is affiliated with Los Angeles Biomedi- 6. Rosansky SJ, et al. Initiation of di- cal Research Institute at Harbor-UCLA alysis at higher GFRs: is the apparent and David Geffen School of Medicine at rising tide of early dialysis harmful or UCLA. Rajnish Mehrotra has received helpful? Kidney Int 2009; 76:257– grant support and honoraria from Baxter 261. Health Care. 7. Kazmi WH, et al. Effect of comorbid- ity on the increased mortality associ- References ated with early initiation of dialysis. 1. US Renal Data System. UADRAoCK- Am J Kidney Dis 2005; 46:887–896. DaE-SRDitUS, Bethesda, MD, Na- 8. Cooper BA, et al. A randomized, con- tional Institutes of Health, National trolled trial of early versus late initia- Institute of Diabetes and Digestive tion of dialysis. N Engl J Med 2010; and Kidney Diseases, 2010. 363:609–619. 2. Keith DS, et al. Longitudinal follow- 9. Jiwakanon S, et al. Peritoneal dialysis: up and outcomes among a popula- an underutilized modality. Curr Opin tion with chronic kidney disease in Nephrol Hypertens a large managed care organization. 2010; 19:573– Arch Intern Med 2004; 164:659–663. 577. 3. US Renal Data System. UADRAoCK- 10. Mehrotra R, et al. Chronic peritoneal DaE-SRDitUS, Bethesda, MD, Na- dialysis in the United States: declin- may be further facilitated by identifying their families should be offered the choice ing utilization despite improving family members or other support services of all dialysis modalities whenever feasible tional Institutes of Health, National outcomes. J Am Soc Nephrol 2007; that may provide assistance to patients to under the oversight and encouragement Institute of Diabetes and Digestive 18:2781–2788. undergo home dialysis (12). Success of this offered by the health care team. and Kidney Diseases, 2009. 11. Mehrotra R, et al. Similar outcomes concept of assisted home peritoneal dialy- In conclusion, there are many unique 4. Kurella Tamura M, et al. Functional sis has been reported from Canada, Den- challenges in the care of elderly ESRD status of elderly adults before and af- with hemodialysis and peritoneal di- mark, and France, and should be consid- patients. These challenges begin from the ter initiation of dialysis. N Engl J Med alysis in patients with end-stage renal ered for appropriate individuals. It follows, time of preparation for dialysis therapy to 2009; 361:1539–1547. disease. Arch Intern Med 2010. then, that the best dialysis modality for a initiation and subsequently the mainte- 5. Carson RC, et al. Is maximum con- 12. Dimkovic NB, et al. Chronic perito- patient is the one that best fits into their nance of dialysis therapy. It is important servative management an equivalent neal dialysis in octogenarians. Neph- lifestyle and their expectations and goals to focus not only on longevity but also on treatment option to dialysis for elder- rol Dial Transplant 2001; 16:2034– for their care. Hence, all patients and/or quality of life and quality of death. ly patients with significant comorbid 2040.

Hypertension in the Elderly: Two Decades Later, What Have We Learned Since the SHEP Trial?

By Madhav Rao and George Bakris

ypertension is common in peo- older individuals, systolic BP is a stronger to various stimuli, loss of integrity of analyses suggest that optimal reduction ple 60 and older. With increas- predictor of cardiovascular disease events various collagen subfractions, and altered in diastolic BP in the elderly should not ing age, it is more likely that and end stage renal disease (5). handling of sodium by the kidney. Some exceed 60–65 mm Hg during attempts someoneH will experience hypertension and contributing factors in the kidney include to reduce the systolic BP below 140 mm die of coronary heart disease even in the Aging and pathophysiology of reduced generation of prostaglandins and Hg. The key exception to this recommen- prehypertension range (1, 2) (Figure 1). hypertension dopamine in response to vasoconstrictor dation is a history of angina; patients so According to the National Health and Nu- Aging is associated with a reduction in ar- stimuli, and increased oxidant stress di- affected should maintain a diastolic pres- trition Examination Survey (NHANES) terial compliance, primarily affecting the rectly mediated by high sodium intake (7, sure >80 mm Hg. 1999 to 2006, approximately 67 percent aorta and other large blood vessels. Altera- 8). Age-associated decline in the activity of adults in the United States 60 and old- of membrane sodium/potassium–ATPase tions of various collagens in the vessel wall Figure 1. Coronary heart er had hypertension, a 10 percent increase decrease elasticity and increase fibrosis and may increase intracellular sodium and re- from NHANES 1988 to 2004 (3). Afri- sclerosis of the blood vessels. As a result, ar- duce sodium–calcium exchange. This in- disease risk in the context can Americans and women had a higher terial stiffness increases, and distensibility creases intracellular calcium and vascular of age and level of BP. Data prevalence of hypertension than did white of the larger arteries decreases, resulting in resistance. Reductions in cellular calcium adapted from Lewington et individuals, and in those 70 and older the efflux due to reduced calcium–ATPase ac- widened pulse pressure. The Framingham al. (1) and Weber (2). hypertension was more poorly controlled Heart Study suggested that both systolic tivity may have a similar effect (9). than in those 60–69 (3) (Figure 2). and diastolic BP increase in parallel un- BP goal in the elderly til the age of 50. Thereafter, systolic BP Definition and significance of continues to rise and diastolic BP drops, The JNC 7 guidelines suggest a goal BP of hypertension resulting in a widened pulse pressure (6). <140/90 mm Hg in all patients, including The Joint National Committee on Preven- Salt sensitivity is defined as an increase the elderly. However, we have learned from tion, Detection, Evaluation and Treatment in systolic pressure of >10 mm Hg over the Systolic Hypertension in Elderly Pro- of High Blood Pressure (JNC 7) defines a few hours after the intake of a fixed gram (SHEP) that among patients with stage 1 hypertension as a systolic BP ≥140 amount of salt. Salt sensitivity plays an isolated systemic hypertension, reduction mm Hg or a diastolic BP ≥90 mm Hg (4). important role in the pathophysiology of diastolic BP below 60–65 mm Hg after Isolated systolic hypertension is a systolic of hypertension in the elderly. Older in- the initiation of antihypertensive therapy BP ≥140 mm Hg but a diastolic BP of ≤90 dividuals are relatively more salt sensitive is associated with higher cardiovascular mm Hg. It affects about two thirds of in- than are people under age 50 because of a event rates. Since the SHEP, several ret- dividuals above age 60 and approximately variety of factors, including reduced nitric rospective studies have supported this 75 percent of those over age 75. Among oxide from the endothelium in response contention (10–12). The results of these Continued on page 14