THE TWO FACES OF
 GERIATRIC CKD




         Joel M. Topf, MD
Modeled laboratory reporting of creatinine versus
MDRD and its effect on death, dialysis and cost
effectiveness
10,000 patients 60+ years old
                   getting yearly evaluations for
                   up to 18 years.

      ...
eGFR performed better than a simple creatinine:
     29 cases of ESRD prevented
     13 premature deaths avoided
eGFR performed better than a simple creatinine:
      29 cases of ESRD prevented
      13 premature deaths avoided
However...
eGFR performed better than a simple creatinine:
      29 cases of ESRD prevented
      13 premature deaths avoided
However...
eGFR performed better than a simple creatinine:
      29 cases of ESRD prevented
      13 premature deaths avoided
However...
2002 National Kidney Foundation Spring Clinical Meeting
K/DOQI Clinical Practice Guidelines
for Chronic Kidney Disease:
Ev...
GFR = 170 x sCr -0.999 x Urea -0.170 x Alb +0.318 x Age -0.176 x (0.762 if female) x
                          (1.18 if Af...
GFR=186 x sCr -1.154 x Age -0.203 x (0.742 if female) x (1.212 African-American)


Levey AS, Greene T, Kusek JW, Beck GJ: ...
Go A, Et al. NEJM 2004; 351: 1296-1305.
Go A, Et al. NEJM 2004; 351: 1296-1305.
Go A, Et al. NEJM 2004; 351: 1296-1305.
Go A, Et al. NEJM 2004; 351: 1296-1305.
JAMA. 2007 Nov 7;298(17):2038-47.
26.3 million Americans
with CKD

50% of Americans over
69 have CKD




   JAMA. 2007 Nov 7;298(17):2038-47.
half of the people
over 70 have CKD
What happens to these patients?
Tromso, Norway, population: 58,000
Tromso, Norway, population: 58,000
Tromso, Norway, population: 58,000

One hospital. One clinical lab.
Tromso, Norway, population: 58,000

One hospital. One clinical lab.

Next nearest lab, 180 miles away
10 year study: Jan 1994 through Dec 2003
10 year study: Jan 1994 through Dec 2003
58,086 people in the city
10 year study: Jan 1994 through Dec 2003
58,086 people in the city

6,863 had an eGFR 30-59
10 year study: Jan 1994 through Dec 2003
58,086 people in the city

3,074 (5%) had 2nd eGFR 30-59 three
mo. after the init...
Patients outcomes. Mean follow-up: 50 months



                                                                2%

      ...
1.00            Renal Failure          Death
                                                               0.84
        0...
Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
2.0
                                                              1.60
   mL/min per year   1.5
                          ...
less renal failure   faster progression
Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
Even though older people
were less likely to have
stable renal function
and had faster loss of
renal function they had a
l...
All patients with a eGFR ≤60 in the year following
       October 1, 2000 who had an additional eGFR ≤ 60 in
       the pr...
209,622 veterans with CKD 3, 4 or 5.
Mean age 73, 47% over 75
97% male




                      Allen Park Veterans Admin...
Incidence of death per 100 person-years
30
                   CKD 4                                         25.4
25
      ...
Incidence of dialysis or transplant per 100 person-years
     25

            20.3
     20                                ...
CKD 4
•   preparation for dialysis

CKD 4   •
        •
            dialysis access surgery
            pre-emptive transplantat...
The geriatric CKD patient
is just an innocent
bystander in the growing
pains of defining and
classifying CKD.
Go A, Et al. NEJM 2004; 351: 1296-1305.
incidence




                      0-19
                         20-44
              75+      1% 13%
              26%


...
28,007 patients 75+ initiated dialysis in 2006
75+ 0-19
                     16% 1% 20-44
                              19%

             65-74

prevalence    20%

     ...
78,126 patients 75+ patients are on dialysis in 2006



                                               dw
The geriatric CKD patient
is just an innocent
bystander in the growing
pains of defining and
classifying CKD.
Geriatric CKD patients
have a higher risk of dying
than progressing to
dialysis but they still
represent the age group
wit...
2%
31%              66%


 No Endpoint     Died
 Renal Failure
2%
31%              66%


 No Endpoint     Died
 Renal Failure
2%
31%              66%


 No Endpoint     Died
 Renal Failure
So they’re on dialysis.
  How do they do?
Hospitalization
                              2.5
Admissions per patient year




                                        ...
ESRD Population    U.S. Population

                             80
Remaining Lifetime (years)




                       ...
Fraction Of Predicted Lifespan Provided By Dialysis


  50%


  40%


  30%


  20%


  10%


  0%
        0-14   20-24   ...
360


Mortality (deaths per 1000 patient years)   300


                                            240


                ...
So they’re on dialysis.
  How do they do?
So they’re on dialysis.
     Pretty well.
Should we be dialyzing
   these patients?
In previous analysis the patients
were compared to younger patients
or patients without kidney disease

This cannot answer...
112 patients                      No diabetes, active
                                  cancer, nephrotic range
70+ years ...
112 patients                      No diabetes, active
                                  cancer, nephrotic range
70+ years ...
VERY LOW PROTEIN

0.3 g protein per kilogram (RDA is 0.8)
  Supplemented with keto-analogs of amino acids
  and 4 essentia...
40 of 56 patients (71%) of patients randomized to diet
initiated dialysis per protocol, median of 9.8 months
after randomi...
Brunori et al. Am J Kidney Dis 2007 vol. 49 p. 569-80
odds ratio for survival, 2.21; 95% CI, 1.02 to
                                                                 4.83; P=0....
Dialysis      Diet (ITT)        Diet (PP)        Diet (on dialysis)


1.2                                   12

0.9       ...
ESRD


Healthy
but old
Multi-specialty clinic

Twelve nephrologists engaged in outpatient CKD
care in a structured CKD clinic at 5 outpatient
cli...
200 consecutive patients

GFR less than 45 mL/min twice, 3 months apart

Age >65

GFR falls below 45 mL/min after Jan 1, 2...
199 patients

117 women, 82 men

150 Caucasians, 48 African Americans, 1 Asian

Average age 75.5 (65-96)

Follow-up:
  Ave...
GFR                  Co-morbidities

 Average 30 mL/min     DM 88 patients

 Minimum 10 mL/min     HTN 194 patients

 Maxi...
OUTCOMES
Died prior to dialysis: 18

End-stage renal disease: 20
                                          10%
  Transplan...
Delta GFR vs follow up


                          40



                          30


                                  ...
initial   delta    Blood
        Age    f/u                                  Hgb
                       eGFR      eGFR    ...
25 OH D
             Ca          Phos         iPTH              25 OH D
                                                Ch...
60
                 ESRD   Death   Alive


                                    45




                                    ...
DIALYSIS ACCESS

All of the ESRD patients received access except the
one preemptively transplanted
                       ...
DIALYSIS ACCESS

None of the 18 patients who died received an access

Of the 161 who are alive and not ESRD, only 3
receiv...
SUMMARY

Our data is fresh and has yet to be vetted by the
skeptical eye of the biostatistician

ESRD appears more common ...
GERIATRIC CKD


Half of patients over 69 have CKD

  Two-thirds of them have CKD stage 3 or higher

Patients are more like...
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
The Two Faces of Geriatric Kidney Disease
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  • Occasionally studies are published which embarrass the specialty
    The story the specialty has been telling, either through editorials or practice guidelines or by the standard of care is suddenly exposed to be more opinion than science by unblinking eye of the RCT
    ACCORD Study showed higher mortality with tight insulin control
    ENHANCE showed that lowering LDL with Zetia did not prevent atherosclerosis
    ILLUMINATE showed that raising HDL did not yield the benefits found with naturally high HDL
    COURAGE showed that PTCA was not helpful for stable coronary disease
    CHOIR
    ATN
    HEMO
  • Occasionally studies are published which embarrass the specialty
    The story the specialty has been telling, either through editorials or practice guidelines or by the standard of care is suddenly exposed to be more opinion than science by unblinking eye of the RCT
    ACCORD Study showed higher mortality with tight insulin control
    ENHANCE showed that lowering LDL with Zetia did not prevent atherosclerosis
    ILLUMINATE showed that raising HDL did not yield the benefits found with naturally high HDL
    COURAGE showed that PTCA was not helpful for stable coronary disease
    CHOIR
    ATN
    HEMO
  • Occasionally studies are published which embarrass the specialty
    The story the specialty has been telling, either through editorials or practice guidelines or by the standard of care is suddenly exposed to be more opinion than science by unblinking eye of the RCT
    ACCORD Study showed higher mortality with tight insulin control
    ENHANCE showed that lowering LDL with Zetia did not prevent atherosclerosis
    ILLUMINATE showed that raising HDL did not yield the benefits found with naturally high HDL
    COURAGE showed that PTCA was not helpful for stable coronary disease
    CHOIR
    ATN
    HEMO
  • Occasionally studies are published which embarrass the specialty
    The story the specialty has been telling, either through editorials or practice guidelines or by the standard of care is suddenly exposed to be more opinion than science by unblinking eye of the RCT
    ACCORD Study showed higher mortality with tight insulin control
    ENHANCE showed that lowering LDL with Zetia did not prevent atherosclerosis
    ILLUMINATE showed that raising HDL did not yield the benefits found with naturally high HDL
    COURAGE showed that PTCA was not helpful for stable coronary disease
    CHOIR
    ATN
    HEMO
  • Occasionally studies are published which embarrass the specialty
    The story the specialty has been telling, either through editorials or practice guidelines or by the standard of care is suddenly exposed to be more opinion than science by unblinking eye of the RCT
    ACCORD Study showed higher mortality with tight insulin control
    ENHANCE showed that lowering LDL with Zetia did not prevent atherosclerosis
    ILLUMINATE showed that raising HDL did not yield the benefits found with naturally high HDL
    COURAGE showed that PTCA was not helpful for stable coronary disease
    CHOIR
    ATN
    HEMO
  • Occasionally studies are published which embarrass the specialty
    The story the specialty has been telling, either through editorials or practice guidelines or by the standard of care is suddenly exposed to be more opinion than science by unblinking eye of the RCT
    ACCORD Study showed higher mortality with tight insulin control
    ENHANCE showed that lowering LDL with Zetia did not prevent atherosclerosis
    ILLUMINATE showed that raising HDL did not yield the benefits found with naturally high HDL
    COURAGE showed that PTCA was not helpful for stable coronary disease
    CHOIR
    ATN
    HEMO


  • Markov chain Monte Carlo analysis
    1000 simulations of 10,000 patients
    between 10 and 180 million patient years














  • defined the stages of ckd 1-5
  • defined how in clinical practice we measure GFR
    except we don’t us this formula which requires three pieces of biochemical data
  • we use this formula which requires only 1, interestingly only published in abstract form.



    lead to an almost immediate push back, re: healthy patients, tranplanters.


  • if you use standard cr use this formula
  • this study really quieted the outrage because instead of focusing on whether the MDRD accurately measured GFR Go showed that it accurately predicted outcomes:
    •Death from any cause
    •Any CV event
    •Any hospitalization
  • this study really quieted the outrage because instead of focusing on whether the MDRD accurately measured GFR Go showed that it accurately predicted outcomes:
    •Death from any cause
    •Any CV event
    •Any hospitalization
  • this study really quieted the outrage because instead of focusing on whether the MDRD accurately measured GFR Go showed that it accurately predicted outcomes:
    •Death from any cause
    •Any CV event
    •Any hospitalization


  • Coresh
    National Health and Nutrition Survey
    direct consequence of defining CKD by GFR are these conclusions: half of the elderly have ckd!



    esrd prevelance increased from 209k to 472k from 1991 to 2004
    incidence increased 43% in the 10 yrs following 1991
    NHANES cross sectional analysis: 88-91, 91-94 (n=15,488) and then: 99-00, 01-02, 03-04 (n=13,233)
  • Coresh
    National Health and Nutrition Survey
    direct consequence of defining CKD by GFR are these conclusions: half of the elderly have ckd!



    esrd prevelance increased from 209k to 472k from 1991 to 2004
    incidence increased 43% in the 10 yrs following 1991
    NHANES cross sectional analysis: 88-91, 91-94 (n=15,488) and then: 99-00, 01-02, 03-04 (n=13,233)
  • Coresh
    National Health and Nutrition Survey
    direct consequence of defining CKD by GFR are these conclusions: half of the elderly have ckd!



    esrd prevelance increased from 209k to 472k from 1991 to 2004
    incidence increased 43% in the 10 yrs following 1991
    NHANES cross sectional analysis: 88-91, 91-94 (n=15,488) and then: 99-00, 01-02, 03-04 (n=13,233)
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • almost immediately following this the push back began
    Hostetter former head of NIDDK
  • Cleveland Clinic and Mayo Clinic
  • Cleveland Clinic and Mayo Clinic
  • Cleveland Clinic and Mayo Clinic
  • Cleveland Clinic and Mayo Clinic
  • Cleveland Clinic and Mayo Clinic
  • Feldman’s Monte Carlo simulation used only patients over 60 and half of the analysis occurred in patients over 69










  • 5% of city with stage 3 ckd compares to 7% on Coresh’s NHANES data
    used 4 v MDRD eq (assumed all people were non-black)
  • 5% of city with stage 3 ckd compares to 7% on Coresh’s NHANES data
    used 4 v MDRD eq (assumed all people were non-black)
  • 5% of city with stage 3 ckd compares to 7% on Coresh’s NHANES data
    used 4 v MDRD eq (assumed all people were non-black)
  • 5% of city with stage 3 ckd compares to 7% on Coresh’s NHANES data
    used 4 v MDRD eq (assumed all people were non-black)
  • renal failure defined as RRT or GFR < 15
    similar to Keith&#x2019;s data from Kaiser Permenente that found 1% risk for CKD 3 at 5 years














  • loss of kidney function averaged 1 mL/min/yr, faster in the elderly
  • loss of kidney function averaged 1 mL/min/yr, faster in the elderly



    clearly this apparent paradox or absurdity is due to the competing morbidity: death, even though they were losing kidney function they were still dying prior to needing the dialysis. this was made more explicit in an earlier study...






  • Found the risk of death of death out weighed the risk of ESRD in the elderly while the opposite was true among younger patients with CKD
    Possibility in a prevalent cohort older patients with CKD are CKD survivors (slow or non-progressive disease)
    CKD in the elderly is a marker for a variety of age-related co-existing conditions so it is a predictor of global health outcomes


  • Found the risk of death of death out weighed the risk of ESRD in the elderly while the opposite was true among younger patients with CKD
    Possibility in a prevalent cohort older patients with CKD are CKD survivors (slow or non-progressive disease)
    CKD in the elderly is a marker for a variety of age-related co-existing conditions so it is a predictor of global health outcomes


































  • only 18.6% of patients &#x2265;75 years compared with 62.5% of patients <65 years were diagnosed with an intrinsic renal disease such as diabetic nephropathy, glomerulonephritis, obstructive nephropathy, interstitial nephritis or polycystic kidney disease.
  • So the lack of a dx was associated with an improved prognosis, as we get better as delaying dialysis with ACEi/ARB/glycemic control we may get more at risk patients in the older age categories.








































  • think about average attendence at an average MLB game That&#x2019;s how many 75+ year olds we are putting on dialysis every year
  • The Two Faces of Geriatric Kidney Disease

    1. 1. THE TWO FACES OF GERIATRIC CKD Joel M. Topf, MD
    2. 2. Modeled laboratory reporting of creatinine versus MDRD and its effect on death, dialysis and cost effectiveness
    3. 3. 10,000 patients 60+ years old getting yearly evaluations for up to 18 years. They ran the simulation 1,000 times Modeled laboratory reporting of creatinine versus MDRD and its effect on death, dialysis and cost effectiveness
    4. 4. eGFR performed better than a simple creatinine: 29 cases of ESRD prevented 13 premature deaths avoided
    5. 5. eGFR performed better than a simple creatinine: 29 cases of ESRD prevented 13 premature deaths avoided However, it also over diagnosed chronic kidney disease: 11,348 times
    6. 6. eGFR performed better than a simple creatinine: 29 cases of ESRD prevented 13 premature deaths avoided However, it also over diagnosed chronic kidney disease: 11,348 times The conclusion was that the high rate of false positives with eGFR reporting prevented the test from being cost effective.
    7. 7. eGFR performed better than a simple creatinine: 29 cases of ESRD prevented 13 premature deaths avoided However, it also over diagnosed chronic kidney disease: 11,348 times The conclusion was that the high rate of false positives with eGFR reporting prevented the test from being cost effective.
    8. 8. 2002 National Kidney Foundation Spring Clinical Meeting K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification
    9. 9. GFR = 170 x sCr -0.999 x Urea -0.170 x Alb +0.318 x Age -0.176 x (0.762 if female) x (1.18 if African-American)
    10. 10. GFR=186 x sCr -1.154 x Age -0.203 x (0.742 if female) x (1.212 African-American) Levey AS, Greene T, Kusek JW, Beck GJ: A simplified equation to predict glomerular filtration rate from serum creatinine. J Am Soc Nephrol 11:A0828, 2000 (abstract)
    11. 11. Go A, Et al. NEJM 2004; 351: 1296-1305.
    12. 12. Go A, Et al. NEJM 2004; 351: 1296-1305.
    13. 13. Go A, Et al. NEJM 2004; 351: 1296-1305.
    14. 14. Go A, Et al. NEJM 2004; 351: 1296-1305.
    15. 15. JAMA. 2007 Nov 7;298(17):2038-47.
    16. 16. 26.3 million Americans with CKD 50% of Americans over 69 have CKD JAMA. 2007 Nov 7;298(17):2038-47.
    17. 17. half of the people over 70 have CKD What happens to these patients?
    18. 18. Tromso, Norway, population: 58,000
    19. 19. Tromso, Norway, population: 58,000
    20. 20. Tromso, Norway, population: 58,000 One hospital. One clinical lab.
    21. 21. Tromso, Norway, population: 58,000 One hospital. One clinical lab. Next nearest lab, 180 miles away
    22. 22. 10 year study: Jan 1994 through Dec 2003
    23. 23. 10 year study: Jan 1994 through Dec 2003 58,086 people in the city
    24. 24. 10 year study: Jan 1994 through Dec 2003 58,086 people in the city 6,863 had an eGFR 30-59
    25. 25. 10 year study: Jan 1994 through Dec 2003 58,086 people in the city 3,074 (5%) had 2nd eGFR 30-59 three mo. after the initial measurement
    26. 26. Patients outcomes. Mean follow-up: 50 months 2% 31% 66% No Endpoint Died Renal Failure Eriksen, Ingebretsen. The progression of CKD: a 10-yr population-based study. Kidney Int (2006) vol. 69 (2) p. 375-82
    27. 27. 1.00 Renal Failure Death 0.84 0.75 0.49 0.50 0.25 0.17 0.07 0.04 0.03 0 <70 70-79 >79 Age C U M U L AT I V E 1 0 Y E A R I N C I D E N C E O F R E N A L FA I L U R E A N D D E AT H I N C K D S TA G E 3 Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
    28. 28. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
    29. 29. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
    30. 30. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
    31. 31. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
    32. 32. 2.0 1.60 mL/min per year 1.5 1.04 1.0 0.50 0.5 0 <70 70-79 >79 LOSS OF GFR BY AGE Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
    33. 33. less renal failure faster progression
    34. 34. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
    35. 35. Even though older people were less likely to have stable renal function and had faster loss of renal function they had a lower risk of renal failure Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82
    36. 36. All patients with a eGFR ≤60 in the year following October 1, 2000 who had an additional eGFR ≤ 60 in the previous 3 months. Creatinine and outcomes were tracked for up to four years (until 9/30/04). O'Hare et al. Age affects outcomes in chronic kidney disease. J Am Soc Nephrol (2007) vol. 18 (10) pp. 2758-65
    37. 37. 209,622 veterans with CKD 3, 4 or 5. Mean age 73, 47% over 75 97% male Allen Park Veterans Administration Hospital, 1949
    38. 38. Incidence of death per 100 person-years 30 CKD 4 25.4 25 CKD 3b 20 CKD 3a 16.5 15.4 15 13.3 11.7 9.9 10 7.6 7.1 6.9 6.1 5.6 4.4 4.3 5 2.9 2.8 2.9 1.8 0 18 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 to 100 Age category
    39. 39. Incidence of dialysis or transplant per 100 person-years 25 20.3 20 CKD 4 17.2 15.0 CKD 3b 15 CKD 3a 9.3 10 6.2 6.3 5 3.6 2.2 2.7 1.3 0.3 0.6 0.3 0.2 0.6 0.1 0.2 0.1 0 18 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 to 100 Age category
    40. 40. CKD 4
    41. 41. • preparation for dialysis CKD 4 • • dialysis access surgery pre-emptive transplantation
    42. 42. The geriatric CKD patient is just an innocent bystander in the growing pains of defining and classifying CKD.
    43. 43. Go A, Et al. NEJM 2004; 351: 1296-1305.
    44. 44. incidence 0-19 20-44 75+ 1% 13% 26% incidence 65-74 45-64 38% 23%
    45. 45. 28,007 patients 75+ initiated dialysis in 2006
    46. 46. 75+ 0-19 16% 1% 20-44 19% 65-74 prevalence 20% 45-64 44%
    47. 47. 78,126 patients 75+ patients are on dialysis in 2006 dw
    48. 48. The geriatric CKD patient is just an innocent bystander in the growing pains of defining and classifying CKD.
    49. 49. Geriatric CKD patients have a higher risk of dying than progressing to dialysis but they still represent the age group with the highest incidence and second highest prevalence of ESRD.
    50. 50. 2% 31% 66% No Endpoint Died Renal Failure
    51. 51. 2% 31% 66% No Endpoint Died Renal Failure
    52. 52. 2% 31% 66% No Endpoint Died Renal Failure
    53. 53. So they’re on dialysis. How do they do?
    54. 54. Hospitalization 2.5 Admissions per patient year 2.20 2.2 2.09 2.08 2.07 1.98 1.99 1.98 2.01 1.94 1.95 1.9 1.6 1.3 1.0 All 20-44 45-64 65-74 75+ All-cause 1996 All-cause 2006
    55. 55. ESRD Population U.S. Population 80 Remaining Lifetime (years) 60 40 20 0 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 89 Age
    56. 56. Fraction Of Predicted Lifespan Provided By Dialysis 50% 40% 30% 20% 10% 0% 0-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84
    57. 57. 360 Mortality (deaths per 1000 patient years) 300 240 180 120 60 0 <20 20-44 45-64 65+ ESRD Transplant General population
    58. 58. So they’re on dialysis. How do they do?
    59. 59. So they’re on dialysis. Pretty well.
    60. 60. Should we be dialyzing these patients?
    61. 61. In previous analysis the patients were compared to younger patients or patients without kidney disease This cannot answer the question: To dialyze or not to dialyze
    62. 62. 112 patients No diabetes, active cancer, nephrotic range 70+ years old proteinuria GFR 5-7 mL/min Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80
    63. 63. 112 patients No diabetes, active cancer, nephrotic range 70+ years old proteinuria GFR 5-7 mL/min Very low protein diet dialysis Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80
    64. 64. VERY LOW PROTEIN 0.3 g protein per kilogram (RDA is 0.8) Supplemented with keto-analogs of amino acids and 4 essential amino acids Initiate dialysis if they develop: symptomatic uremia volume overload uncontrollable hypertension hyperkalemia Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80
    65. 65. 40 of 56 patients (71%) of patients randomized to diet initiated dialysis per protocol, median of 9.8 months after randomization. Mortality was equal in the two groups: 31 deaths in the dialysis group 28 in the diet group Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80
    66. 66. Brunori et al. Am J Kidney Dis 2007 vol. 49 p. 569-80
    67. 67. odds ratio for survival, 2.21; 95% CI, 1.02 to 4.83; P=0.04). Brunori et al. Am J Kidney Dis 2007 vol. 49 p. 569-80
    68. 68. Dialysis Diet (ITT) Diet (PP) Diet (on dialysis) 1.2 12 0.9 9 0.6 6 0.3 3 0 0 admission/year Hosp days/year Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80
    69. 69. ESRD Healthy but old
    70. 70. Multi-specialty clinic Twelve nephrologists engaged in outpatient CKD care in a structured CKD clinic at 5 outpatient clinics
    71. 71. 200 consecutive patients GFR less than 45 mL/min twice, 3 months apart Age >65 GFR falls below 45 mL/min after Jan 1, 2004 Retrospective chart review Endpoints: death, ESRD, hospitalizations
    72. 72. 199 patients 117 women, 82 men 150 Caucasians, 48 African Americans, 1 Asian Average age 75.5 (65-96) Follow-up: Average 3.2 years 639 patient years
    73. 73. GFR Co-morbidities Average 30 mL/min DM 88 patients Minimum 10 mL/min HTN 194 patients Maximum 45 mL/min CAD 90 patients CVA 21 patients Ca 62 patients
    74. 74. OUTCOMES Died prior to dialysis: 18 End-stage renal disease: 20 10% Transplant 1 9% Hemodialysis 18 Peritoneal dialysis 1 81% ESRD Death No endpoint
    75. 75. Delta GFR vs follow up 40 30 Average progression 1.1 mL/min per year 20 loss of GFR (ml/min/yr) 10 0 0 1 2 3 4 5 6 7 8 9 10 -10 -20 -30 -40
    76. 76. initial delta Blood Age f/u Hgb eGFR eGFR pressure ESRD 74.1 1,028 21 4.5 147/73 11.3 Death 76.2 775 28 6.1 136/74 11.6 Alive 75.6 1,235 30 0.1 140/72 12.5
    77. 77. 25 OH D Ca Phos iPTH 25 OH D Checked ESRD 8.9 4.0 159.9 10% 10.5 Death 9.1 3.7 146.5 22% 23.5 Alive 9.3 3.5 95.6 29% 23.2 Only 2, 4, and 47 patients had 25 OH vitamin D checked
    78. 78. 60 ESRD Death Alive 45 30 15 DM CAD 0 CVA PVD Ca
    79. 79. DIALYSIS ACCESS All of the ESRD patients received access except the one preemptively transplanted Quinton Of the 18 who started hemodialysis: 6% Fistula 7 fistulas Pcath 39% 33% 4 grafts Graft 6 permacaths 22% 1 Temporary quinton
    80. 80. DIALYSIS ACCESS None of the 18 patients who died received an access Of the 161 who are alive and not ESRD, only 3 received an access All received AVF March of 2007, most recent visit March 2009 December 2006, most recent visit March 2009 May 2007, most recent visit March 2008
    81. 81. SUMMARY Our data is fresh and has yet to be vetted by the skeptical eye of the biostatistician ESRD appears more common with lower eGFR higher PTH faster progression
    82. 82. GERIATRIC CKD Half of patients over 69 have CKD Two-thirds of them have CKD stage 3 or higher Patients are more likely to die than develop to ESRD Despite this it is the fastest growing age demographic with ESRD
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