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The Two Faces of Geriatric Kidney Disease

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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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