Dialysis in elderly patients wkd 2014

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Dialysis in elderly patients wkd 2014

  1. 1. Dialysis in Elderly World Kidney Day 2014 Kalba Dr. Muhamed AL Rohani, MD, FISN
  2. 2. Dialysis in elderly Age: Definition: Calendar age Biological age Diseases Genetic Environment Evaluation of elderly pt Age Comorbidity Metal status QoL Life expectancy Initiation of RRT Vascular state Compliance to RRT Socio-economical state
  3. 3. 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
  4. 4. The CKD Continuum ESRDCKD Diabetes Hypertension 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 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 RightReturn • Reduce Repeat Hospitalization • Medication Reconcilliation • Integrated return to chronic dialysis care Early CKD Care impacts Late CKD Outcomes
  5. 5. CV Mortality in the General Population and in Patients with Kidney Failure AnnualMortality(%) GP Male GP Female GP Black GP White Dialysis Male Dialysis Female Dialysis Black Dialysis White Transplant 100 10 1 0.1 0.01 25–34 35–44 45–54 55–64 65–74 75–84 > 85 Age (years) 0.001 Sarnak, MJ et al. Hypertension 2003; 42: 1050-1065. One year mortality 46%
  6. 6. 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.
  7. 7. DOPPS study: 46 – 55 % of pts aged ≥ 75yrs had coronary artery disease. Myocardial dysfunction LF low EF LVH due to hypertension Increase 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
  8. 8. Geriatric Syndromes Mental health disturbance: Depression Difficult to be diagnosed Heterogeneity of causes (chronic infection, malnutrition, malignancies, electrolyte imbalance and drugs) Dementia, Delirium Can be treated but only 10% treated, Cognitive impairment Disabilities, Falls: Fractures related to osteoporosis Hip fractures Mortality and morbidity Multimorbidity management Challenges of providing optimal care QoL Short life expectancy Compliance to treatment polypharmacy). Number of drugs Drug 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.
  9. 9. Four topics method for analysis of ethical problems in clinical medicine adapted to the geriatric patient with CKD/ESRD 1. Medical indications for intervention 1. 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 QoL 2. The QoL is a value judgment and personal 3. There are some objective criteria 1. End-stage dementia 2. Cachexia 3. Advanced cancer 4. There is a significant symptom burden 4. Contextual features 1. Loyalty and fairness 2. Health resources and care 3. Family supportive 4. Conflicts between family members 5. Cultural or religious background 6. Conflict among the health care providers
  10. 10. 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).
  11. 11. 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
  12. 12. ESRDCKD Diabetes Hypertension 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 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 RightReturn • Reduce Repeat Hospitalization • Medication Reconcilliation • Integrated return to chronic dialysis care Mircroalbuminuria GFR Compensation By unaffected nephrons Treatment The CKD Continuum
  13. 13. 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
  14. 14. Timely Referral Leads to Reduced Mortality 0% 10% 20% 30% 40% < 1 month 1-4 mos > 4 mosOneYearMortalityRate Timing of Referral to Nephrologist (Time Prior to Start of Dialysis) Impact of Timing of Referral to Nephrologist on Mortality 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 Dialysis Was Reduced by 48% For Early Referral Patients Compared to Late Referral Patients. 2 Several Other Studies Shown Below Confirm This.
  15. 15. Transplantation: Survival advantage in elderly pts, Waiting list and age; only 8% of pts on waiting list are elderly Comorbidity preclude transplantation Higher rate of complications: Surgical Infections Malignancy Conservative care : Poor outcome Multiple comorbidities on dialysis In 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 status Electrolytes imbalance Acidosis Some pts has longer life than those on dialysis, QoL no comparison study,
  16. 16. NKF K/DOQI GUIDELINES: Clinical Practice Guidelines and Clinical Practice Recommendations 2006 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.”
  17. 17. 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
  18. 18. AVF in elderly Conflicting studies No difference survival between young and elderly high rate of failure to mature High rate of failure in 1st yr Late referral Failure of AVF to mature 85% 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:
  19. 19. Hypertension Arterial stiffness Vascular calcification sBP elevation Renal artery stenosis RAASactivity CKD – MBD ? Nitric oxide gloemrulosclerosis Hypertension as risk factor JNC 8: In the general population aged 60 years, initiate pharmacologic treatment to 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
  20. 20. 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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