Geriatric Nephrology Has Come of Age: At Last, 2009 ASN
Geriatric Nephrology The incidence of new patients with ESRD: over the age of 65 yr -over 65 yr-old: double in next 20yr -over 85 yr-old: 38% growth during the 1990s -75 yr-old: average 3.5 chronic disease 2.CKD patients: most of whom are elderly 65-74 yr:~25%, 75-85 yr:~35%, 85+yr:~45%
The Coming Pandemic of CKD/ESKD and the Aging Population 70대가 말기신부전 발병의 절정!
Why Do We Need a Geriatric NephrologyCurriculum? • This older population will bring their problems to the nephrologists. • Dialysis patients rely on their nephrologists for most of their care.
“신장내과 의사가 80% 문제 해결”
“의료공급자를 단순화-비용, 부작용 줄임”
Drug Dosing and Renal Toxicity in the Elderly Patient 인식, 감각,기억력 고령환자에서 약물부작용: 3-10배 신장질환: 부작용 급증
Drug in the Elderly Patient
Drug Dosing and Renal Toxicity in the Elderly Patient • Review patients past medical history and medication: drug–drug interactions • For GFR<50 ml/min: adjust drugs according to the renal function • Dosage modification: dose reduction, dosing interval prolongation, or both methods • Consider therapeutic drug monitoring (TDM) in older patients with renal impairment 최소로 단순하게 약을 투여하여야!
Medication in the elderly
Acute Kidney Injury in the Elderly • Elderly patients: at higher risk for the AKI • Hemodynamic, metabolic, and molecular changes increased susceptibility to injury • Multiple etiologies are often operative in the development of AKI. • The outlook for renal recovery is likely impaired in the elderly patient. (단지 28% 회복률)
Acute Kidney Injury in the Elderly
Decision Making 건강취약 허약 VES: Vulnerable Elders Survey, ADL: Activities of Daily Living
ACOVE stage (Assessing Care of Vulnerable Elders) • Healthy/usual(건강): might be a transplant candidate • Vulnerable(취약):typical dialysis candidate, Geriatric assessment and intervention plans may slow the progression of geriatric susceptibility factors • Frail(허약): should be considered for a nondialytic treatment plan or a time- limited dialysis trial. Final decisions will hinge on patient preferences, QOL, and contextual issues
삶의 궤적 투석환자 사망률:24%/년, 입원율66%/년 80대, 90대 투석환자 사망률: 46%/년 이상적인 치료 Dialysis patient disease trajectory
The trajectory of care during chronic illness 임종, 존엄사, well-dying
Hypertension in the Elderly
President FD Roosevelt dying of a cerebral hemorrhage on April 12, 1945, and his physician, AR McIntire, declaring that “it had come out of the clear sky,” even though Roosevelt was known to have had Hypertension and CRF for more than ten years.
Non-adherence to treatment Comorbidity, Life style “I’ve also been treating the high cholesterol and then I stopped the medicine because I got my cholesterol down low. And, I had in the past, a little blood pressure problem, which I treated and then I got it down…” Former US President Clinton, awaiting coronary bypass surgery, calls into Larry King Live from his hospital bed; Sept 3, 2004,
Isolated systolic hypertension, elderly hypertension -associated with elevated cardiac output, such as anemia, hyperthyroidism, aortic insufficiency, AV fistula, and Paget’s disease of bone. -most cases are caused by reduced elasticity and compliance of large arteries resulting from age and from the atherosclerosis-associated accumulation of arterial calcium and collagen and the degradation of arterial elastin. Increasing PWV, raising the peak systolic BP.
Mean Blood Pressure According to Age and Race or Ethnic Group in U.S. Adults NEJM 2007;357:789-796
Frequency of Untreated Hypertension According to Subtype and Age NEJM 2007;357:789-796
Pseudohypertension -When BP measurements are elevated, but the BP is actually normal. -As people get older, the walls of the arteries sometimes get very thick, and calcium may be deposited in the arterial wall. This makes the arteries very stiff and difficult to compress.
Doctors usually suspect pseudohypertensionin cases where: -The BP reading is very high over time, but the patient has no signs of organ damage or other Cx. -Attempting to treat the measured high BP causes symptoms of low BP (dizziness, confusion, decreased UO)
Osler’s maneuver The Osler maneuver is performed by palpating the pulseless radial or brachial a. distal to the point of occlusion of the a. by the sphygmo- manometric cuff. When either of these a. remains palpable (despite being pulseless), the patient is described as “Osler positive.” In contrast, when either a. collapses and becomes impalpable, the patient is “Osler negative.” Osler in 1892, Messerli et al in 1985 Nowadays, Inappropriate, Upper limb PWV, Intraarterial BP
White Coat Hypertension
-Patients were 60 years old or more. Systolic BP was 160 mm Hg or greaterand diastolic BP was less than 95 mm Hg. -8 trials, 15,693 patients, were followed up for 3.8 years. Active treatment reduced total mortality by 13% (95% CI 2–22, p=0·02), cardiovascular mortality by 18%, all cardiovascular complications by 26%, stroke by 30%, and coronary events by 23%. Lancet 2000; 355: 865–872
Lancet 2000; 355: 865–872
N=15,963 F/U for 3.8yr 30% 23% 26% 13% Summarised results in older patients with isolated systolic hypertension enrolled in 8 trials of antihypertensive drug treatment Lancet 2000; 355: 865–872
-Leiden, The Netherlands. -599 inhabitants of the birth-cohort 1912–1914 were enrolled on their 85th birthday. There were no selection criteria related to health or demographic characteristics. The mean follow-up was 4.2 years. During follow-up 290 participants died, 119 due to cardiovascular causes. J Hypertension 2006, 24:287–292
N=599 F/U for 4.2 yr Cumulative all-cause mortality depending on systolic and diastolic BP at age 85 years. J Hypertension 2006, 24:287–292
High BP at baseline (age 85 yr) was not a risk factor for mortality. Baseline BP values below 140/70 mmHg (n = 48) were associated with excess mortality, predominantly in participants with a history of hypertension Confounding poor health status! pitfall of observation study J Hypertension 2006, 24:287–292
Randomly assigned 3845 patients who were 80 years of age or older and had a sustained systolic BP of 160 mm Hg or more to receive either the diuretic indapamide (sustained release, 1.5 mg) or matching placebo. The ACE inhibitor perindopril (2 or 4 mg) was added if necessary to achieve the target BP of 150/80 mm Hg. N Engl J Med 2008;358:1887-98
HYVET Study: HTN in the very elderly trial(>80yr) Placebo (1912 patients) active-treatment (1933 patients) Median follow-up =1.8 years. Mean BP According to Study Group N Engl J Med 2008;358:1887-98
HYVET Study: HTN in the very elderly trial(>80yr) N=3845, F/U=1.8 yr N Engl J Med 2008;358:1887-98
Isolated Systolic Hypertension in the Elderly NEJM 2007:357;789-796
Isolated Systolic Hypertension in the Elderly NEJM 2007:357;789-796
Antihypertensive drugs JNC 7, Five major classes: AABCD ACE inhibitors, ARB, β-adrenergic blockers, CCB, diuretics ESH, ESC, British guideline -no preference to diuretics -argue against diuretics and β blockers In two thirds of patients with hypertension, two or more drugs will be required to achieve target BP levels. “Combination therapy”
Strategies for Improving BP Control Fail to treat: inadequate patient education, physician empathy, and social support; the presence of coexisting diseases; complex dose regimens; problems with transportation of the patient, side effects and the cost of medications. Cooperation: physician, nurse clinicians, physicians’ assistants, and pharmacists A low starting dose and a gradual increase (e.g., every 2 to 4 weeks): in frail, immobile and diabetes patients
Area of Uncertainty -Clinical studies are not enough. -Exact measurement of BP -Pseudohypertension -Old age? Extreme old age(80 yr) -Target BP? 150/80 mmHg -Systolic BP: >160 mmHg 140-159 mmHg, no studies -Subgroup analysis: heart dz, DM, storke, CKD, not mobile pt
Summaries Geriatric Nephrology -Geriatrics; multiple pathology, polypharmacy -Pandemic of CKD/ESKD; cardiovasccx, infection, multiple cx -Adverse drug reaction -AKI on CKD Hypertension in the elderly -misconception, non-adherence -pseudoHTN, white coat HTN -isolated hypertension -HYVET study: sys BP>160 target BP 150/80 mmHg -Subgroup? -Target BP? Patient to patent, comorbidity, PseudoHTN