Dialysis in ElderlyWorld Kidney Day 2014

Kalba

Dr. Muhamed AL Rohani, MD, FISN

Dialysis in elderly Age:

Definition:Calendar age Biological age

Diseases GeneticEnvironment

Evaluation of elderly ptAgeComorbidityMetal status QoLLife expectancy

Initiation of RRTVascular stateCompliance to RRTSocio-economical state

Glomerulosclerosis

Atherosclerosis

Tubular atrophy

Interstitial fibrosis

Kidney aging:

Physiological renal aging (senescence): Biopsy:

Drop of GFR

Hypertrophy and hyperfunction of

unaffected nephrons

Decomposition off other nephrons

The CKD Continuum

ESRDCKDDiabetesHypertension

Obesity

CVD

Advanced CKD Care• 30-20-10 & Timely Referral• Promote Co-management and

Coordinated Care • Multidisciplinary Team Care in

Nephrology • Vascular Access management• Case Management

– Diabetes– Nutrition & Obesity– Hypertension & CVD

• Treatment Options Education

Advanced CKD Care• 30-20-10 & Timely Referral• Promote Co-management and

Coordinated Care • Multidisciplinary Team Care in

Nephrology • Vascular Access management• Case Management

– Diabetes– Nutrition & Obesity– Hypertension & CVD

• Treatment Options Education

RightStart• At Renal Replacement

Therapy Start Reduce:• Mortality• Hospitalization• CHF

• Transplant & Home Therapies when possible

• Support for:• Permanent Access• Nutrition• Adequate Dialysis• Anemia, Bone

Mgmt

RightStart• At Renal Replacement

Therapy Start Reduce:• Mortality• Hospitalization• CHF

• Transplant & Home Therapies when possible

• Support for:• Permanent Access• Nutrition• Adequate Dialysis• Anemia, Bone

Mgmt

PCP & Nephrology Practice

• Public Awareness• Screening of “At Risk”

patients• Recommended evaluation

and monitoring of CKD• Timely Referral to

Nephrology• Education for Patients

PCP & Nephrology Practice

• Public Awareness• Screening of “At Risk”

patients• Recommended evaluation

and monitoring of CKD• Timely Referral to

Nephrology• Education for Patients

RightReturn• Reduce Repeat Hospitalization• Medication Reconcilliation• Integrated return to chronic

dialysis care

Early CKD Care impacts Late CKD Outcomes

CV Mortality in the General Population and in Patients with Kidney Failure

CV Mortality in the General Population and in Patients with Kidney Failure

An

nu

al M

ort

alit

y (%

)A

nn

ual

Mo

rtal

ity

(%) GP Male

GP Female

GP Black

GP White

Dialysis Male

Dialysis Female

Dialysis Black

Dialysis White

Transplant

GP Male

GP Female

GP Black

GP White

Dialysis Male

Dialysis Female

Dialysis Black

Dialysis White

Transplant

100100

1010

11

0.10.1

0.010.01

25–3425–34 35–4435–44 45–5445–54 55–6455–64 65–7465–74 75–8475–84 > 85

Age (years)Age (years)

0.0010.001

Sarnak, MJ et al. Hypertension 2003; 42: 1050-1065.

One year mortality 46%

Comprehensive geriatric assessment (CGA):

Geriatric assessment tools include: Comorbidity (Charleson Comorbidity Index),Functional status (Karnofsky scale, Katz and Barthel Index), Physical performance (Timed Get up and Go test; timed walking speed), Frailty testing (Frailty Phenotype4), cognition (MMSE, mini-cog), Psychologic status (Geriatric Depression Scale), Nutrition, Medication review, Urinary incontinence, Visual/ hearing impairment, Social support.

CGA can be followed serially and used in medical decision-making as elderly patients and their families are faced with challenges such as treatment for cancer, surgery, percutaneous gastrostomy tube insertion, nursing home placement, withdrawal of intensive care unit (ICU) care, and dialysis decisions.

DOPPS study:

46 – 55 % of pts aged ≥ 75yrs had coronary artery disease. Myocardial dysfunctionLF low EF LVH due to hypertensionIncrease risk of hypotension during HD Increase risk of pulmonary edema

25 – 30% cerebrovascular disease Up to 50% had CHF and peripheral vascular dis.

40% of pts were unable to walk without assistance and 75% of the elderly has frailty

The repeated hypotension leads to hemodynamic instability and end-organ hypoperfusion finishing woth cardiac events, cerebral dysfunction, and stroke. Malnutrition – inflammation syndrome and loss of residual renal function

Higher rate of catheter use as vascular access with great risk of death Poor AVF maturation

The problem of transport to HD-center

Geriatric SyndromesMental health disturbance:

Depression Difficult to be diagnosed Heterogeneity of

causes (chronic infection, malnutrition, malignancies, electrolyte imbalance and drugs)

Dementia, DeliriumCan be treated but only 10% treated,

Cognitive impairmentDisabilities,

Falls: Fractures related to osteoporosisHip fractures Mortality and morbidity

Multimorbidity management Challenges of providing optimal care QoL Short life expectancy Compliance to treatment polypharmacy).

Number of drugsDrug interaction

Categorization of pts based on estimated life expectancy and functional level: 1- robust older people,: life expectancy ≥ 5 yrs, functionally independent, not needing help from caregivers.

2- frail older people : Life expectancy > 5 yrs, Significantly functional impairment requiring help from caregivers

3- moderately demented older people: Life expectancy 2 – 10 yrs, May or may not be functionally impaired

4- end-of-life older people : Life expectancy < 2 yrs.

Four topics method for analysis of ethical problems in clinical medicine adapted to the geriatric patient with CKD/ESRD

1. Medical indications for intervention1. Beneficence and nonmalfeasance 2. Prognosis/benefits versus burdens 3. What is the functional age? 4. Is this patient frail?5. What are the geriatric susceptibility

factors and survival data?6. Base in the above:

1. Is the patient candidate for dialysis or nondialytic treatment

2. Patient preferences respect for autonomy

1. Established a “big picture” goals and outcome

2. Explore patient`s personal narrative 3. Higher prevalence of cognitive

dysfunction and inability to make decisions

4. Role of family

3. Quality of life 1. There is no universal metric for QoL2. The QoL is a value judgment and

personal 3. There are some objective criteria

1. End-stage dementia 2. Cachexia3. Advanced cancer

4. There is a significant symptom burden

4. Contextual features 5. Loyalty and fairness 6. Health resources and care 7. Family supportive 8. Conflicts between family members 9. Cultural or religious background 10. Conflict among the health care

providers

Copyright restrictions may apply.

Murtagh, F. E. M. et al. Nephrol. Dial. Transplant. 2007 22:1955-1962; doi:10.1093/ndt/gfm153

(A) Kaplan–Meier survival curves for those with ischaemic heart disease, comparing the dialysis and conservative groups (log rank statistic 1.46, df 1, P = 0.27).

(B) Kaplan–Meier survival curves for those without ischaemic heart disease, comparing the dialysis and conservative groups (log rank statistic 12.78, df 1, P < 0.0001).

Survival of patients aged ≥75 years initiating dialysis in Australia between January 2002 and December 2005 (Kaplan–Meier curves) with 95% CIs compared with survival of 75- and 80-

year-olds from the general Australian population [23].

Foote C et al. Nephrol. Dial. Transplant. 2012;ndt.gfs096

© The Author 2012. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com

ESRDCKD

DiabetesHypertension

Obesity

CVD

atherosclerosis

Advanced CKD Care• 30-20-10 & Timely Referral• Promote Co-management and

Coordinated Care • Multidisciplinary Team Care in

Nephrology • Vascular Access management• Case Management

– Diabetes– Nutrition & Obesity– Hypertension & CVD

• Treatment Options Education

Advanced CKD Care• 30-20-10 & Timely Referral• Promote Co-management and

Coordinated Care • Multidisciplinary Team Care in

Nephrology • Vascular Access management• Case Management

– Diabetes– Nutrition & Obesity– Hypertension & CVD

• Treatment Options Education

RightStart• At Renal Replacement

Therapy Start Reduce:• Mortality• Hospitalization• CHF

• Transplant & Home Therapies when possible

• Support for:• Permanent Access• Nutrition• Adequate Dialysis• Anemia, Bone

Mgmt

RightStart• At Renal Replacement

Therapy Start Reduce:• Mortality• Hospitalization• CHF

• Transplant & Home Therapies when possible

• Support for:• Permanent Access• Nutrition• Adequate Dialysis• Anemia, Bone

Mgmt

PCP & Nephrology Practice

• Public Awareness• Screening of “At Risk”

patients• Recommended evaluation

and monitoring of CKD• Timely Referral to

Nephrology• Education for Patients

PCP & Nephrology Practice

• Public Awareness• Screening of “At Risk”

patients• Recommended evaluation

and monitoring of CKD• Timely Referral to

Nephrology• Education for Patients

RightReturn• Reduce Repeat Hospitalization• Medication Reconcilliation• Integrated return to chronic

dialysis care

Mircroalbuminuria

GFR Compensation

By unaffected nephrons

Treatment

The CKD Continuum

Nephrology Care and CKD Outcomes

Control of Risk Factors for CKD Progression and Adverse Outcomes

Late Referral to Nephrology (all patients were receiving Primary

Care)

Early Referral to Nephrology

Blood Pressure control(to recommended goal)

39% 69%

HbA1c <7% 44% 82%

ACEI/ARB use(for proteinuria >1 g/day)

36% 96%

Anemia treatment(to recommended goal)

9% 52%

Nutritional Status Management 65% 81%

Fluid & Volume control 67% 83%

- Int J Clin Pract 2010, Herget-Rosenthal

Timely Referral Leads to Reduced Mortality

< 1 month 1-4 mos > 4 mos0%

10%

20%

30%

40%

Impact of Timing of Referral to Nephrologist on Mortality

Timing of Referral to Nephrologist(Time Prior to Start of Dialysis)

On

e Y

ear

Mort

ality

Rate

Early Referral Late Referral

90 Day Mortality 3 3% 13%

6 Month Mortality 4 13% 31%

1 Year Mortality 5 6% 39%

1 Year Mortality 2 22% 41%

2 Year Mortality 6 56% 69%

2

5

In a Recent Study of 300 Medicare Beneficiaries,the Risk of Death in the First Year on DialysisWas Reduced by 48% For Early Referral Patients Compared to Late Referral Patients. 2 Several Other Studies Shown Below Confirm This.

Transplantation: Survival advantage in elderly pts, Waiting list and age; only 8% of pts on waiting list are elderly Comorbidity preclude transplantationHigher rate of complications:Surgical Infections Malignancy

Conservative care : Poor outcomeMultiple comorbidities on dialysisIn UK it is maximum management without

dialysis In Australia 14% of elderly pts choose

conservative care The care focus on

anemia,, HTN, CKD-MBD, fluid statusElectrolytes imbalanceAcidosis

Some pts has longer life than those on dialysis,

QoL no comparison study,

NKF K/DOQI GUIDELINES:Clinical Practice Guidelines and Clinical Practice

Recommendations2006 Updates

Hemodialysis Adequacy

“…the recommended timing of dialysis therapy initiation is a compromise designed to maximize patient QOL by extending the dialysis-free period while avoiding complications that will decrease the length and quality of dialysis-assisted life.”

Quality of life during dialysis:

In UK dialysis population grew by 29% (2005 -2008) in USA the rate is more Median survival is 28.9 months

Quality of life:In Canada within 6 months 30% required

community support or transfer to a nursing home, and 22% still alive after 1 yr.

Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients

Conclusion: The findings from this study support the greater use of PD in older people, and suggest that there may be

substantial under-utilisation in many centres in the UK. The fact that QOL may well be better on PD due to its potentially lower intrusion into older peoples’ lives should influence the content of predialysis education. Improved education would enable patients to choose dialysis modality based on how it is going to affect their ability to maintain the aspects of life they value.

HD or PD ? Patient RRT modalities:

Base on physicians and family Patients mostly go to HD Residual renal function

There is no clear evidence regarding the difference in QoL for pts with HD and PD

AVF in elderlyConflicting studies No difference survival between young and elderly high rate of failure to matureHigh rate of failure in 1st yr

Late referralFailure of AVF to mature85% of pts 2/3 continue > 3 months

The effect of atherosclerosis

The co-existence of heart failure

The maturity time for AVF

Increased risk of death

Factors affecting the outcome:

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Hypertension

Arterial stiffness

Vascular calcification

sBP elevation

Renal artery stenosis

RAAS activity

CKD – MBD ?

Nitric oxide

gloemrulosclerosis

Hypertension as risk factorJNC 8: In the general population aged 60 years, initiate pharmacologic treatmentto lower blood pressure (BP) at systolic blood pressure (SBP)150 mmHg or diastolic blood pressure (DBP)90mmHg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A)

In the population aged 18 years or older with CKD and hypertension, initial antihypertensive treatment should include an ACEI or ARBto improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status.Moderate Recommendation – Grade B

Withdrawal of Dialysis – Third Leading Cause of Death

• Shared decision making• Informed consent• Estimate prognosis• Advanced directives• Time limited trials• Palliative care

RPA/ASN

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