-Bosnia-PD-elderl_y.ppt

1. The Elderly Patient and
Peritoneal Dialysis
Fredric O. Finkelstein
Clinical Professor of Medicine
Yale University
New Haven, CT USA

2. Points to be Covered
• Increasing number of elderly patients with
ESRD
• Need to be clear about the goals and
objectives of therapies
• PD has certain advantages as well as
disadvantages in the elderly
• Certain issues need to be kept in mind in
discussing PD utilization in the elderly

3. Questions to be Answered
• Why are so few elderly patients on PD?
• Is there a higher mortality or complication rate
in elderly patients on PD compared to HD?
• Is there a higher technique failure and/or
peritonitis rate in the elderly PD patient
compared to younger patients?
• Is the quality of life worse in the elderly patient
on PD than on HD?
• What can we do to improve the quality of life of
the elderly patient maintained on PD?

4. Incidence of ESRD by Age USRDS 2015

5. Population trends: the aging population (U.S. data)
People >65
1900: 3 million
2000: 35.6 million
2030: 71.5 million
People >85:
2000: 4 million
2050: 20 million
(five fold increase)

6. Lucas Cranach: The Fountain of Youth, 1546, Berlin Gemalderie

7. Thomas Cole: Voyage of Life: Youth, 1842, National Gallery, Washington

8. Thomas Cole: The Voyage of Life: Old Age, 1842, National Gallery, Washington, DC

9. What Is the Goal of Treatment?
• Alleviate symptoms?
• Prevent development of symptoms?
• Maximize longevity?
• Conform to standard guidelines?

10. Indications to Start Dialysis
Urgent Indications
• Pericarditis
• Acute neurological
problems
• Metabolic problems
• Unmanageable fluid
overload
“Uremic” symptoms
• Fatigue
• Lethargy
• Cognitive impairment
• Neuropathy
• Uremic pruritus
• Sleep disorders
• Anorexia, nausea
• Restless leg syndrome

11. Symptom Burden in CKD/ESRD
• Pain (proprioceptive or neuropathic, nociceptive)
• Pruritis
• Sleep disorders
• Restless legs
• Depression
• Anxiety
• Impaired physical functioning
• Loss of energy, vitality
• Sexual dysfunction
• Cognitive dysfunction
• Impact of the dialysis regimen
(e.g. post hemodialysis recovery time)
• GI symptoms: anorexia,
nausea, constipation,
diarrhea
• Cardiac symptoms: chest
pain, edema, DOE, etc
Key Question: to what
extent are the symptoms
impacting on the patient’s
quality of life? Risks of
treatment vs the benefits

12. How Does the Initiation of Dialysis Impact On
These Symptoms: CHOICE Study Wu et al JASN 2004 15:743-53
• Changes were examined over 1 yr using the CHEK
questionnaire includes the SF-36 and 14 dialysis specific domains
• On the 8 SF-36 domains, 20 to 31% of patients had
a worsening, 42 to 60% had no change, and 19 to
28% had an improvement
• In the dialysis specific domains, 19 to 30% had a
worsening, 50 to 65% had no change, and 16 to
24% had an improvement

13. Problems with Dialysis
Peritoneal Dialysis
• Rigid daily dialysis routine
• Weight gain: dextrose
• Glucose control
• Peritoneal inflammation
• Peritonitis, exit site
infections
• Monthly visits to dialysis
facility
Hemodialysis
• Myocardial stunning
• Cerebral injury
• Post dialysis recovery time
• Sepsis
• Vascular access problems
• 3 or more treatments/week
• Transportation to dialysis
facility

14. • A minimal Kt/V urea of 1.7, representing the sum of
peritoneal and residual renal function)
• Anuric patients: a peritoneal Kt/V of 1.7
• No evidence of improvement in outcomes with higher
doses of dialysis:
a) WK Lo et al: Kidney Int. 2003 64:649-56
b) ADEMEX trial: Paniagua R et al: J Am Soc Nephrol 2002
13:1307-20
c) Fried et al: AJKD 52:1122-30, 2008
APPROPRIATE PRESCRIPTION:
ISPD Recommended Adequacy Targets
(Lo WK et al: Guideline On Targets For Solute And Fluid Removal In Adult Patients
On Chronic Peritoneal . PDI 2006 26:520-2)
14

15. Why Is The Dosing So Important?
• Underscores an emphasis of limiting dextrose
exposure
• Enables one to think creatively about the dialysis
prescription and the “burden” of the treatment
(impact on the patient)

16. What Is The Rational Approach?
• Measure RRF as KT/V at start of dialysis
• Prescribe enough dialysis to achieve a
KT/V of 1.7 to 2.0 (combined RRF and PD)
• There is no benefit to achieving a KT/V
>2.0

17. New Haven Protocol
• Patient is going to start PD: measure a 24
hour urine for KT/V urea
• Model dose of PD necessary to achieve a
KT/V >1.7 but <2.0
• Preferred model: 2 exchanges per day for
those with endogenous KT/V of 1 or higher
• Discuss with patient the need to increase
dose if RRF declines

18. Other Options
• Dialysis 5 or 6 days/week
• Low dose cycler therapy with a dry day
• 2 exchanges per day – with part of the day
dry

19. Assisted PD
• Nurses or trained individual attaches patients to
cycler and disconnects in the morning (French
model)
• Trained individual sets machine up during day
and patient makes connections and
disconnections (Canadian and UK model)
• Family member(s) assist (U.S. and other
countries model)
• Nursing home or rehabilitation facility does PD

20. Incident Dialysis Patients: % on PD and HD :
USRDS
0
10
20
30
40
50
60
70
80
90
100
0-19 20-44 45-64 65-74 >75
PD
HD

21. Prevalent Dialysis Patients: % on PD and HD
USRDS
0
10
20
30
40
50
60
70
80
90
100
0-19 20-44 45-64 65-74 75+
PD
HF

22. Potential problems associated
with elderly PD patients
• High frequency of co-morbid diseases,
including vascular disease and arthritis
• Impaired mobility
• Cognitive difficulties
• Living environment: potential problem
• Nutrition
• Compliance with home regimen

23. But What Does the Data Show
for Elderly Patients on PD?
• No difference in mortality rates compared
to HD patients
• Higher mortality rate compared to younger
patients
• No difference in overall peritonitis rates
compared to younger patients
• No difference (or lower) technique failure
rate compared to younger patients

24. lla
illi
lla
illi
USRDS: Cumulative probability of changing
status, by age: death as endpoint

25. USRDS: Cumulative probability of modality change, by age:

26. Technique failure: death and transplant
excluded (42 centers, 1487 patients)
Finkelstein et al PDI 11:274, 1991

27. New Haven Study: PD in the Elderly
Age (years) < 50
(n=166)
50-64
(n=135)
>65
(n=192)
% on APD 92 94 92
Diabetes% 31 62 61
Kadambi et al: Seminars in Dialysis 2002

28. Technique and Patient Survival of Elderly on PD
Kadambi et al: Seminars in Dialysis 2002
Group 1: < 50,
Group 2: 50-64,
Group 3: > 65

29. Peritonitis in Elderly on APD
(New Haven: Kadambi et al)
Rate* <50 yrs 50-64yrs >65 yrs
Gram pos 1/20.0 1/20.0 1/30.2
Gram neg 1/125.0 1/98.0 1/62.4 a
* Infections per patient months a P < 0.05

30. 0
10
20
30
40
50
60
Gram
Positive (%)
Gram
Negative (%)
Fungal (%) Culture
negative and
others (%)
Group 1 1/23.6
patients-months
Group 2 1/23 patients-
months
Group 1: 235 Patients age 75 or older
Group 2: < 60 years of age

31. New Haven Study: PD in the
Elderly: QofL Data
Age (years) < 50
(n=166)
50-64
(n=135)
>65
(n=192)
% on APD 92 94 92
Diabetes% 31 62 51
SF-36 MCS 46.8+8.8 48.9+7.6 48.6+7.0
SF-36 PCS 36.5+9.7 37.1+8.3 31.2+1.9
Kadambi et al: Seminars in Dialysis 2002

32. EAPOS STUDY
• 2 years outcome study of 177 anuric APD
patients in Europe
• Median age of 54 years (range 21-91 years)
• Targeted creat clearance of 60 L/week and
ultrafiltration of > 750 cc/day

33. Technique Survival
<65
>65
0 3 6 9 12 15 18 21 24
Months
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
Cumulative
Proportion
Surviving
> & = 65 yrs
p=0.57
<65 yrs
EAPOS: Age and Technique Survival

34. North Thames Dialysis Study
(NTDS)
• 12 month prospective cohort study to evaluate
clinical outcomes, quality of life (QOL) and costs
in elderly dialysis patients
• Elderly defined as > 70 years old at start of
dialysis
• Chronic dialysis defined according to the USRDS
90 day rule
• All eligible patients from 4 centers included in
study
Lamping et al, Lancet 2000; Harris S et al, PDI 2002

35. Sociodemographic characteristics: NTDS
HD (n=96) PD (n=78) P value
Incident 42 (44%) 36 (46%) 0.76
Age (yrs) 70 – 93 70 – 91 0.76
Male sex 60 (62%) 55 (70%) 0.33
Comorbidity 0
1
2
20 (21%)
32 (33%)
44 (46%)
19 (24%)
29 (37%)
30 (39%)
0.62
Social class
(non-manual)
51 (53%) 44 (56%) 0.76
Prevalence of
social risk
14 (19%) 9 (14%) 0.49
* Social risk - living alone and unable to cope with self care

36. Mortality, hospital admissions
and costs NTDS Lamping et al, Lancet 2000,
Harris et al: PDI 22:463, 2002
HD (n=95) PD (n=76)
Alive at 12 months 73 (77%) 58 (76%)
Mortality rate (deaths/100 pt-yrs) 26.4 26.1
Hospitalisation rate* 2.01 1.88
Dialysis-related and in-patient
costs. Mean (SD), £ sterling
23,199
(4,469)
19,574
(5,726)
*Admissions/patient-year

37. Adjusted Estimates of Outcomes
HD v PD Harris S et al, PDI 2002
Outcome RR PD/HD 95% CI P value
Mortality 0.99 0.51 - 1.93 0.97
Hospitalisation 0.88 0.69 - 1.12 0.29

38. Quality of Life (QOL) in Peritoneal Dialysis (PD) and Hemodialysis
(HD) Patients
P D H D p Value
SF-36 PCS Baseline 34.7 32.7 0.23
6 months 35.5 30.1 0.006
12 months 32.0 31.6 0.83
SF-36 MCS Baseline 52.5 49.9 0.10
6 months 54.6 53.1 0.32
12 months 54.6 52.6 0.36
KDQOL sx Baseline 85.4 81.6 0.019
6 months 85.2 79.7 0.003
12 months 82.0 80.0 0.35

39. Reasons to transfer to HD
42%
25%
7%
10%
16%
Psychosocial
Peritonitis
Loss of UF
Medically Required
Others
New Haven Experience

40. Beavers Timerlawn Family Evaluation Scale
chaos marked dominance respectful egalitarian
dominance negotiation
1 2 3 4 5 6 7 8 9
1-3= low 4 – 6 = mid 7 - 9 = high
Family Dynamics Are Important

41. Percent Transfers attributed to
Psychosocial Family Rating
• Family dynamics
scored with Beavers
Timberlawn
Evaluation scale
• Cause of technique
failure attributed by
dialysis staff
0
10
20
30
40
50
60
low
(1-3)
mid
(4-6)
high
(7-9)
%
transfers
Carey et al Adv Perit Dial 6:26-29, 1990

42. Transfers within the first year for patients
> 60 years of age for psychosocial reasons
0
10
20
30
40
50
60
70
low mid high
% patients
transferring
family score

43. EXTENDED CARE FACILITIES AND CPD
• Reasonable option for
elderly patients on
dialysis
• Markedly reduced
global costs
• We have trained over
10 ECFs and have
cared for over 350
patients since 1993
• Peritonitis rate of 1 per
24 patient months
• Useful for both short
and long term stays

44. CONCLUSIONS
• PD is a reasonable treatment for elderly patients with
ESRD
• It is important to keep in mind the goals of therapy and
be flexible about the dose of dialysis
• Mortality in elderly patients on PD is higher than in
younger patients, but not higher than in HD patients of
comparable age
• Technique failure rates and peritonitis rates are not higher
in elderly patients (? lower)
• Quality of life measures are similar in elderly HD and PD
patients
• Mental QofL scores are similar in elderly and younger
patients

45. ISSUES THAT NEED SPECIAL
ATTENTION IN THE ELDERLY
• Assessment of cognitive function
• Assessment of family dynamics
• Attention to GI problems, bowels
• Ongoing assessment of quality of life issues
• Support and availability to patient, family