DOCSLIB.ORG

Chapter 37: Dialysis Decisions in the Elderly Patient with Advanced CKD and the Role of Nondialytic Therapy

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Chapter 37: Dialysis Decisions in the Elderly Patient with Advanced CKD and the Role of Nondialytic Therapy Chapter 37: Dialysis Decisions in the Elderly Patient With Advanced CKD and the Role of Nondialytic Therapy Mark Swidler Renal Division, Mount Sinai School of Medicine, New York, New York THE GERIATRIC PERSPECTIVE ON Barthel Index), physical performance (Timed Get up MEDICAL DECISION MAKING and Go test; timed walking speed), frailty testing (Frailty Phenotype4), cognition (MMSE, mini-cog), What is most important to older adults is maintain- psychologic status (Geriatric Depression Scale), nutri- ing independence and quality of life (QOL) through tion, medication review, urinary incontinence, visual/ optimal mental capacity and physical functioning. hearing impairment, and social support. These can Dialysis decisions in elderly persons must move be- used to generate prognostic models for mortality, hos- yond the traditional GFR-related indications for di- pitalization, and loss of functional independence.5–9 alysis initiation and incorporate geriatric principles The presence of combinations of functional im- that focus on assessment of function, disabilities, pairments and geriatric syndromes will influence comorbidities, and geriatric syndromes (e.g., frailty, prognosis, shared decision-making, and the ability dementia, delirium, depression, falls, malnutrition, to tolerate renal replacement therapy. As a person polypharmacy). These geriatric syndromes are ages, functional status becomes as useful as comor- powerful predictors of adverse outcomes including bidity in risk assessment. It can improve mortality mortality, hospitalization, nursing home place- prediction in patients Ͼ80 yr and lead to more ac- ment, and hip fractures. Chronic kidney disease curate risk adjustment.6,7 Functional data and the (CKD), uremia, and dialysis accelerate these out- documentation of limitations are essential to dialy- comes, especially the expression and progression of sis decision analysis. frailty in predisposed patients. Chronological age Categorization of elderly patients based on esti- alone should not be a factor in the dialysis decision mated life expectancy and functional level is helpful tree, although it is associated with an increased risk to use as a starting framework for informed discus- of death. Each elderly patient must be approached sions about medical decisions. One model (Clinical individually. Glidepaths10,11) uses the following four categories: Geriatricians use validated standardized tools robust older people (life expectancy Ն 5 yr, func- for staging the functional age of their patient and tionally independent, and not needing help from look for signs that increase risk for disability and caregivers); frail older people (life expectancy Ͼ 5 affect morbidity and mortality. A comprehensive yr, significant functional impairment requiring geriatric assessment (CGA) obtained at baseline to help from caregivers); moderately demented older define overall health status forms the basis for indi- people (life expectancy 2 to 10 yr, may or may not vidualized diagnostic and therapeutic interventions be functionally impaired); and end-of-life older and allows for both a general and prognostic cate- people (life expectancy of Ͻ2 yr). gorization.1 A CGA can be followed serially and Other models developed in geriatric oncolo- used in medical decision-making as elderly patients gy1,12–15 use modified geriatric assessment para- and their families are faced with challenges such as digms to evaluate the risks and benefits of therapy treatment for cancer, surgery, percutaneous gas- trostomy tube insertion, nursing home placement, withdrawal of intensive care unit (ICU) care, and Correpondence: Mark Swidler, Renal Division, Mount Sinai dialysis decisions. Geriatric assessment tools2,3 include School of Medicine, 1 Gustave L. Levy Place, New York, NY evaluations of comorbidity (Charleson Comorbidity 10029. E-mail: [email protected] Index), functional status (Karnofsky scale, Katz and Copyright ᮊ 2009 by the American Society of Nephrology American Society of Nephrology Geriatric Nephrology Curriculum 1 in elderly cancer patients. This has not been formally studied in ESRD exemplifies the disease trajectory characterized by CKD/ESRD but the concept is similar. Dialysis has been com- long-term complications punctuated by acute medical epi- pared with cancer in terms of mortality, adverse effects, and sodes (Figure 1).18 Renal replacement may correct uremia but symptom burden. Classification of a prospective elderly dialy- the disease trajectory continues. sis patient into one of the following general “functional age” CKD and dialysis are risk factors for adverse geriatric out- categories begins the dialysis decision process (Table 1). comes. Decreasing GFR and dialysis are associated with step- • Healthy/usual: this is the most optimal dialysis patient who might also wise increases in rates of the following: functional limita- be a transplant candidate. tions,21 which, independent of the cause, are associated with • Vulnerable: this is a more typical dialysis candidate. Geriatric assess- increased mortality, hospitalization, and long-term care22; ment and intervention plans (e.g., rehabilitation, pain control, treat- frailty syndrome,23 which predicts falls, mobility/activities of ment of cognitive deficits and depression, limiting polypharmacy, pre- daily living (ADL) disability, hospitalization, and death among venting falls, instituting home services) may slow the progression of 4 24 geriatric susceptibility factors that will adversely affect prognosis, QOL, community elders and ESRD patients ; cognitive dysfunc- and the dialysis experience. tion25 (hemodialysis patients with dementia have a survival • Frail: This is a suboptimal dialysis candidate and should be considered probability of 30% at 2 yr versus 60% in their nondemented for a nondialytic treatment plan or a time-limited dialysis trial. Final counterparts, a 50% reduction in life expectancy)26; falls and decisions will hinge on patient preferences, QOL, and contextual issues falls-related injury (including hip fracture), which are signifi- (see Method for Evaluating Dialysis Decisions). cant predictors of mortality27; hospitalization,28 which in older adults is associated with a high incidence of multiple adverse Epidemiology of CKD/Dialysis in the Elderly outcomes, including functional decline, delirium, and falls29; Although dialysis is life-sustaining therapy and extends life, it nursing home complications, where the yearly death rate is two may also create, increase, or prolong suffering while not restor- times that of the general Ͼ65-yr-old ESRD population [cogni- ing or maintaining function in selected subgroups of geriatric tive/physical impairment is significant, with approximately patients. Recent studies suggest that dialysis may not offer a 60% showing moderate to severely impaired decision-making survival advantage in patients over the age of 75 with multiple skills, with no advanced directives in 60 to 65%, and do not comorbidities and cardiac ischemia.17 resuscitate (DNR) in 25 to 30%]30; and increasing symptom Dialysis has the attributes of a serious and progressive burden.31,32 chronic illness including (1) reduced lifespan versus age- CKD, uremia, and dialysis will accelerate these geriatric matched nondialysis patients; (2) progressive disability; (3) re- outcomes in predisposed patients. The elderly CKD stage 4 to 5 peated hospitalizations; (4) significant comorbidity; (5) high patient who presents with “geriatric susceptibility factors” symptom burden; and (6) caregiver stress. Table 1. Functional age (stages of aging1) categories with clinical measures ACOVE Stage* Healthy/Usual Vulnerable Frail VES-13 score† 0–2 3–6 7ϩ Walking speed (m/s)‡ Ͼ0.77 Ͻ0.42 Chair stand time¶ (sec)§ Ͻ11.2 Unable, Ͼ60 Frailty score¶ 0 1–2 3–5 Syndromes** 0 1 2ϩ Remaining life expectancy†† High Middle Low Common geriatric assessment measures ADLs 0 1 2ϩ Instrumental ADLs 0 1 2ϩ Mini Mental State Examination Ͼ26 23–26 Ͻ23 Geriatric Depression Scale 0 5 6ϩ Polypharmacy (no.of medications per day) Ͻ5 5–8 9ϩ Comorbidity None limiting Slight Severe Adapted from reference 1. Reprinted with permission. ᮊ 2008 American Society of Clinical Oncology. All rights reserved. *ACOVE (Assessing Care of Vulnerable Elders) is a project that uses quality indicators to identify and treat noninstitutionalized vulnerable elders (http:// www.rand.org/health/projects/acove/acove3/). †The Vulnerable Elders Survey (VES-13) (http://www.rand.org/health/projects/acove/survey.html) is a self-administered brief function-based tool for screening community-dwelling populations to identify older persons at risk for adverse outcomes and has been studied in cancer patients. A score of Ն3 identifies vulnerable adults at risk for geriatric deficits, functional decline, and death16 ‡Walking speed-distance 4 m/15 ft at patient’s usual speed. §Time it takes for patient to rise from a straight chair five times as quickly as possible. ¶Validated frailty screening tool with five frailty components: (1) Ͼ10-lb weight loss in last year; (2) poor endurance (self-report tool); (3) low physical activity (self-report tool); (4) slow walking time (s/15 ft); (5) weak grip strength (hand dynamometer); Ն3 criteria present ϭ positive for frailty phenotype.4 **Dementia, delirium, depression, falls. ††See reference 1, Table 2, p. 1938 and reference 15. 2 Geriatric Nephrology Curriculum American Society of Nephrology Characterized by: - functional decline months to years - episodes of acute (serious) complications - 1 year probability
Load more

Recommended publications
  • Chronic Kidney Disease in the Elderly: Evaluation and Management
    Review For reprint orders, please contact: [email protected] 11 Review Chronic kidney disease in the elderly: evaluation and management Clin. Pract. Chronic kidney disease (CKD) is a very common clinical problem in elderly patients Mary Mallappallil1, Eli A and is associated with increased morbidity and mortality. As life expectancy continues Friedman1, Barbara G to improve worldwide, there is a rising prevalence of comorbidities and risk factors Delano1, Samy I McFarlane2 ,1 such as hypertension and diabetes predisposing to a high burden of CKD in this & Moro O Salifu* 1Division of Nephrology, SUNY population. The body of knowledge on the approach to elderly patient with CKD Downstate Medical Center, Brooklyn, is still evolving. Thus, this review seeks to explore the epidemiology and to discuss NY 11203, USA current understanding of challenges in the diagnosis and management of elderly 2Department of Endocrinology, SUNY patients CKD. Downstate Medical Center, Brooklyn, NY 11203, USA Keywords: chronic kidney disease • CKD • elderly • GFR • MDRD • old age • risk *Author for correspondence: factors • US Tel.: +1 718 270 1584 Fax: +1 718 270 3327 [email protected] Although considerable interest continues elderly with CKD, as of 2005 the Accredi- to mount on diseases of the elderly, there is tation Council for Graduate Medical Edu- no universally accepted definition of elderly cation included geriatric nephrology train- particularly in patients with chronic kidney ing in the core curriculum for nephrology disease (CKD). In 1935, the USA passed the f ellowship [6]. first Social Security Act, using age 65 years as the age of retirement and the age at which a Prevalence of CKD in the elderly person became eligible for government wel- There is a high prevalence of CKD in the fare benefits[1] .
    [Show full text]
  • BOSTON UNIVERSITY MEDICAL CENTER DEPARTMENT of MEDICINE ANNUAL REPORT SECTION of Preventive Medicine & Epidemiology JULY 1, 2007 - JUNE 30, 2008 FISCAL YEAR 2008
    BOSTON UNIVERSITY MEDICAL CENTER DEPARTMENT OF MEDICINE ANNUAL REPORT SECTION OF Preventive Medicine & Epidemiology JULY 1, 2007 - JUNE 30, 2008 FISCAL YEAR 2008 Overview of Section The Section of Preventive Medicine and Epidemiology is a non-clinical section of the Evans Department of Medicine, with both a research and an educational mission. The research focus of the Section largely comprises the epidemiology and prevention of chronic diseases such as cardiovascular disease, obesity, diabetes or cancer. The study of behavioral and other lifestyle factors in the pathogenesis of these diseases and conditions is of particular interest. Other ongoing work includes studies of biomarkers of chronic diseases in conjunction with various behavioral exposures. The faculty and staff of the Section have extensive and long-standing expertise in nutritional epidemiology, including the selection and implementation of various nutritional assessment methods (e.g., diet records, 24-hour recalls, food frequency questionnaires), management, use and analysis of large USDA and other nutrient data bases and data sets, and the linkage of food and nutrient information to determine food consumption patterns for individual study participants and to compare those patterns with USDA Food Pyramid Guidelines. This technical expertise is used to guide the study of nutrition-related exposures and various health outcomes. The study of food-based dietary patterns has been a major focus of many of the epidemiologic studies carried out in the Section during the past year. These include studies of dietary patterns such as the “DASH diet” or a Mediterranean-style diet. The causes and consequences of obesity and body fat distribution throughout the lifespan are other important areas of interest to the Section.
    [Show full text]
  • Research Article Interstitial Fibrosis and Tubular Atrophy In
    International Journal of Medical Science and Clinical Invention 5(05): 3784-3788, 2018 DOI:10.18535/ijmsci/v5i5.05 ICV 2016: 77.2 e-ISSN:2348-991X, p-ISSN: 2454-9576 © 2018,IJMSCI Research Article Interstitial Fibrosis and Tubular Atrophy in Nephrectomy Patients with Unilateral Kidney Obstruction Zuhirman Zamzami, M.D, Urologist, Ph.D Urology Division,Surgery Department, Medical Faculty, Riau University Abstract: Background: Activation of interstitial myofibroblasts and extracellular matrix deposits in unilateral kidney obstruction results in hydronephrosis, there will be depletion of the renal parenchyma, tubular atrophy and the formation of interstitial fibrosis. The aim of the study was to assess the profile of interstitial fibrosis and tubulus atrophy in nephrectomy patients with unilateral obsruction. Methodology: We reviewed medical records and histopathology examinations of patients with unilateral kidney obstruction underwent nephrectomy in Arifin Achmad Regional Hospital, Pekanbaru, Riau Province of Indonesia in 2012- 2017. Statistic analysis used were univariate. Approval on the study was obtained from the Ethical Review Board for Medicine and Health Research, Medical Faculty, RiauUniversity. Results: There were 77 unilateral kidney obstruction patients underwent nephrectomies in Arifin Achmad Regional General Hospital of Riau Province in which mostly 23 (29.9%) in age 50-59 years old patients. with males were in 55.8% patients and females were in 44.3% patients. Most blood ureum level <40 mg / dl was in 81.8% patients and most blood creatinine level was <1.5 mg / dl in 79.2% patients. The most etiology was miscellaneous in 15.6%. The results of histopathologic examination were interstitial fibrosis and tubular atrophy respectively in 51.8% patients.
    [Show full text]
  • Geriatric Nephrology: Responding to a Growing Challenge
    Special Feature Geriatric Nephrology: Responding to a Growing Challenge Mitchell Rosner,* Emaad Abdel-Rahman,* and Mark E. Williams† for the ASN Advisory Group on Geriatric Nephrology *Division of Nephrology, University of Virginia, Charlottesville, Virginia; and †Harvard Medical School, Beth Israel Deaconess Medical Center, Joslin Diabetes Center, Boston Massachusetts Changing demographics of the global population predict that the number of people age 65 years or greater will triple over the coming decades. Because the incidence and prevalence of kidney disease increase with advancing age, nephrologists will be increasingly confronted with a population of patients who are elderly and have a large number of comorbid conditions requiring ongoing care. Furthermore, it is increasingly understood that aging leads to its own unique aspects of nephrologic diagnosis and treatment. Although it is known that elderly patients constitute a group with special needs and present unique challenges to the nephrologist, traditional nephrology fellowship training has not included a focus on the geriatric population. In response to this need for greater education and awareness, the American Society of Nephrology has initiated a program of educational activities in geriatric nephrology and has chartered a specific advisory council. The priority being given to geriatric nephrology is a hopeful sign that issues such as treatment options, the efficacy of treatments, and their effect on quality of life for the elderly patient with kidney disease will be improved in the coming years. Clin J Am Soc Nephrol 5: 936–942, 2010. doi: 10.2215/CJN.08731209 t is a fact of life—we are getting older. Whether viewed from increased 3-fold during the 20th century, the elderly population a national or global perspective, nephrologists need to ready (age Ͼ65 years) increased more than 10-fold.
    [Show full text]
  • Special Considerations for Dialysis in the Elderly
    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.
    [Show full text]
  • Anatomy and Physiology of Ageing 4: the Renal System
    Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Keywords: Ageing/Respiratory system/Respiratory tract infections/ Systems of life This article has been Renal system double-blind peer reviewed In this article... l How age affects the normal functioning of the renal system l Age-related changes to the kidneys, bladder, urethra and prostate l How declining renal function can affect various conditions in older age Anatomy and physiology of ageing 4: the renal system Key points Authors Maria Andrade and John Knight are both senior lecturer in biomedical The renal system science, College of Human Health and Science, Swansea University. 1is the most powerful regulator Abstract The functions of the renal system include removal of waste products; of the body’s regulation of blood volume, blood pressure and red blood cells; and balancing of internal environment electrolytes and blood pH. Renal function starts to gradually decline after the third With advancing decade of life but, in the absence of disease, the renal system is able to fulfil its role 2age, renal blood throughout life. In spite of this, many anatomical and physiological changes mean flow – and therefore older people are prone to issues such as polyuria, nocturia and incontinence. This glomerular filtration fourth article in our series on the anatomy and physiology of ageing explains how age rate – are reduced affects the organs of the renal system, leading to a reduction in renal function. The mass and 3weight of the Citation Andrade M, Knight J (2017) Anatomy and physiology of ageing 3: the renal kidneys decrease system.
    [Show full text]
  • Chapter 19: Nocturia in Elderly Persons and Nocturnal Polyuria
    Chapter 19: Nocturia in Elderly Persons and Nocturnal Polyuria Dean A. Kujubu Department of Medicine, UCLA School of Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California Nocturia is defined by the International Conti- Conditions such as congestive heart failure, ne- nence Society as the interruption of sleep one or phrotic syndrome, autonomic neuropathy, and ve- more times at night to void.1 Although nocturia is nous insufficiency lead to interstitial edema forma- relatively uncommon among younger adults, by 80 tion during the day. Mobilization of the yr of age, the prevalence rises to 80 to 90% in both accumulated interstitial fluid while recumbent re- men and women.2 The presence of nocturia dis- sults in nocturia. Obstructive sleep apnea is associ- rupts sleep, leading to daytime somnolence, depres- ated with excessive atrial natriuretic peptide pro- sive symptoms, cognitive dysfunction, and a re- duction. Neurologic dieases, such as Alzheimer’s duced sense of well being and quality of life.3 disease and Parkinson’s disease, are associated with Moreover, nocturia is associated with an increased alterations in the diurnal secretory pattern of neu- risk morbidity and even mortality.4,5 rohormones, such as natriuretic peptides and anti- diuretic hormone. Patients with chronic kidney dis- ease are unable to maximally concentrate their PATHYPHYSIOLOGY urine and often must void at night. In many cases, the cause of nocturnal polyuria is Although it is commonly assumed that nocturia in undefined. In idiopathic nocturnal polyuria, As- the elderly is primarily a urologic problem, such plund and Aberg8 suggested that anti-diuretic hor- thinking is inaccurate.
    [Show full text]
  • Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline
    Journal of Clinical Medicine Concept Paper Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline Piccoli Giorgina Barbara 1,2,* ID , Breuer Conrad 3, Cabiddu Gianfranca 4 ID , Testa Angelo 5, Jadeau Christelle 6,† and Brunori Giuliano 7,† 1 Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy 2 Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France 3 Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France; [email protected] 4 Nephrology, Brotzu Hospital, 09100 Cagliari, Italy; [email protected] 5 Association ECHO, 44000 Nantes, France; [email protected] 6 Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France; [email protected] 7 Nefrologia, Ospedale di Trento, 38100 Trento, Italy; [email protected] * Correspondence: [email protected]; Tel.: +39-0033-6697-33371 † The authors contributed equally to this manuscript. Received: 29 June 2018; Accepted: 1 August 2018; Published: 3 August 2018 Abstract: Nephrology is a complex discipline, including care of kidney disease, dialysis, and transplantation. While in Europe, about 1:10 individuals is affected by chronic kidney disease (CKD), 1:1000 lives thanks to dialysis or transplantation, whose costs are as high as 2% of all the health care budget. Nephrology has important links with surgery, bioethics, cardiovascular and internal medicine, and is, not surprisingly, in a delicate balance between specialization and comprehensiveness, development and consolidation, cost constraints, and competition with internal medicine and other specialties. This paper proposes an interpretation of the different systems of nephrology care summarising the present choices into three not mutually exclusive main models (“scientific”, “pragmatic”, “holistic”, or “comprehensive”), and hypothesizing an “ideal-utopic” prevention-based fourth one.
    [Show full text]
  • End of Life and Decision Making in Elderly Persons with Kidney Failure
    Chapter 38: End of Life and Decision Making in Elderly Persons With Kidney Failure Richard Swartz and Erica Perry Division of Nephrology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan DEATH AND DYING IS INEVITABLE IN Case 1 NEPHROLOGY PRACTICE Several months after the death of a very loving man who did home hemodialysis (HD) for many years Mortality rates for end-stage kidney disease (ESKD) with his wife’s help, the dialysis social worker received in the United States are well established through an angry and critical letter from his teenage daughter, decades of national surveillance1 and consistently blaming herself but also asking why no one had pre- average 15 to 20% per year for all patients who do pared her family for her father’s loss. She described not receive a kidney transplant. Thus, if one works how she and her sisters regretted not having the chance in a chronic dialysis unit of 70 patients, one can to say a loving goodbye to their father and how bereft expect to encounter at least one death per month. In their mother felt at his loss. the acute hospital setting, multiple studies2,3 have verified that patients who develop acute renal fail- This particular case occurred early in our career ure severe enough to require renal replacement with ESKD, and although we had an open relation- therapy have a 50% chance of dying in the hospital ship with the patient and his family, we failed to talk irrespective of the type of renal replacement used about death and dying because we felt that it was a and despite all of the technology presently available taboo subject and because we thought that we to support attendant multiorgan comorbidity.
    [Show full text]
  • The Diagnosis of Renal Disease in the Elderly As an Unmet Need. a Position Paper Endorsed by Ital
    Journal of Nephrology https://doi.org/10.1007/s40620-019-00584-4 POSITION PAPERS AND GUIDELINES Beyond chronic kidney disease: the diagnosis of Renal Disease in the Elderly as an unmet need. A position paper endorsed by Italian Society of Nephrology (SIN) and Italian Society of Geriatrics and Gerontology (SIGG) Filippo Aucella1 · Andrea Corsonello2 · Dario Leosco3 · Giuliano Brunori4 · Loreto Gesualdo5 · Raffaele Antonelli‑Incalzi6 Received: 19 September 2018 / Accepted: 27 December 2018 © The Author(s) 2019 Abstract The dramatic increase in prevalence of chronic kidney disease (CKD) with ageing makes the recognition and correct refer- ral of these patients of paramount relevance in order to implement interventions preventing or delaying the development of CKD complications and end-stage renal disease. Nevertheless, several issues make the diagnosis of CKD in the elderly cumbersome. Among these are age related changes in structures and functions of the kidney, which may be difficult to distin- guish from CKD, and multimorbidity. Thus, symptoms, clinical findings and laboratory abnormalities should be considered as potential clues to suspect CKD and to suggest screening. Comprehensive geriatric assessment is essential to define the clinical impact of CKD on functional status and to plan treatment. Correct patient referral is very important: patients with stage 4–5 CKD, as well as those with worsening proteinuria or progressive nephropathy (i.e. eGFR reduction > 5 ml/year) should be referred to nephrologist. Renal biopsy not unfrequently may be the key diagnostic exam and should not be denied simply on the basis of age. Indeed, identifying the cause(s) of CKD is highly desirable to perform a targeted therapy against the pathogenetic mechanisms of CKD, which complement and may outperform in efficacy the general measures for CKD.
    [Show full text]
  • Online Geriatrics Curriculum
    Chapter 1: Geriatric Nephrology Has Come of Age: At Last Dimitrios G. Oreopoulos* and Jocelyn Wiggins† *Department of Medicine, University of Toronto, Toronto, Canada; and †University of Michigan, Ann Arbor, Michigan On May 23–24, 1985, the first International Sym- ease (MDRD) formula has revealed a large number posium on Geriatric Nephrology was held in To- of patients who have impaired kidney function, ronto. In his excellent review of the symposium,1 most of whom are elderly. Primary care physicians Michael Kay commented on the challenges and are inundated with elderly patients with impaired risks facing aged individuals and, in view of the in- kidney function and, in turn, are flooding the neph- creased costs of their care, the ethical issues facing rologists with referrals. the caregiver. His report stressed the fact that “the Nephrologists have had to take a serious look at degree of humanity in our healthcare world will be the plight of elderly, and probably as a result, three made evident in the way we treat (or do not treat) important developments have ushered in the new our minorities, our underprivileged, our poor, our era of Geriatric Nephrology. mentally infirm, those who have no voice to speak for themselves, and finally, the aged.” 1. For the first time, the American Society of Nephrology has in- cluded in its annual Renal Week program a 2-d course on geri- After that successful initial meeting, the Interna- atric nephrology that was sold out and that kept the interest of tional Society of Geriatric Nephrology was formed, the participants to the end.
    [Show full text]
  • Comprehensive Geriatric Assessment in Nephrology REVIEW ARTICLE
    REVIEW ARTICLE Port J Nephrol Hypert 2019; 33(3): 168-175 • Advance Access publication 27 September 2019 Comprehensive geriatric assessment in nephrology Ana Farinha1, Sofia Duque2 1 Nephrology Department, Centro Hospitalar de Setúbal 2 Orthogeriatric Unit (Coordinator), Internal Medicine Department, Centro Hospitalar de Lisboa Ocidental ABSTRACT In Portugal, in 2018, 64.5% of dialysis patients were elderly and nearly a quarter were older than 80 years. Aging is a heterogeneous process: in some patients, there is a marked clinical improvement under renal replacement therapy (RRT) although others show an inexorable functional decline. Despite advances in dialysis, patient mortality rates remain high. These two phenomena have been difficult to understand and it may be difficult to decide which patients may benefit from RRT or conservative care. Comprehensive Geriatric Assessment (CGA) is an instrument used by geriatricians to evaluate functionality and geriatric syndromes, allowing recognition of problems that would not otherwise be identi- fied. It has been used to individualize and tailor therapies. CGA allows frailty identification (the major geriatric syndrome) and might better predict clinical prognosis and interventions’ effectiveness. Physical frailty is a multifactorial condition that is common in chronic kidney disease (CKD) patients and its reversibility is hardly predictable when RRT is started so CGA might contribute to a better understanding of frailty in these patients. Therefore, it is possible that CGA application to CKD older patients would contribute to the selection of patients who might benefit the most from RRT and to improve patient clinical condition. This article aims to review geriatric syndromes and frailty in CKD patients, CGA potential to evaluate them and possible models to apply it.
    [Show full text]