The document discusses chronic kidney disease in elderly patients. It notes that the elderly population is growing rapidly and will more than double between 2000 and 2030. Chronic kidney disease is also an epidemic among the elderly, as aging leads to a decline in kidney function even without other risk factors. Outcomes of chronic kidney disease and end-stage renal disease are generally worse in elderly patients compared to younger patients due to higher rates of comorbidities. Management of chronic kidney disease in the elderly requires an individualized approach balancing treatment goals with patient preferences and prognosis. Palliative care is also an important part of care for elderly patients with advanced chronic kidney disease or end-stage renal disease.
A limited presentation about a) age related renal functional changes b) management of CKD, including advance care planning and transplantation referral c) management of potentially risky drugs in the elderly with CKD (NOACs)
A limited presentation about a) age related renal functional changes b) management of CKD, including advance care planning and transplantation referral c) management of potentially risky drugs in the elderly with CKD (NOACs)
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Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
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- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/i_bUFU-p43Q
Arabic Language version of this lecture is available at:
https://youtu.be/RaIP09m4XMY
- Visit our website for more lectures: www.NephroTube.com
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- Follow us on twitter: www.twitter.com/NephroTube
Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/h3HRvWGUj5A
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
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Chronic Kidney Disease Challenges and New SolutionsViewics
A critical population management challenge concerns chronic kidney disease (CKD), which impacts about half of the Medicare population and of diabetics. More than 50% of adults over 30 years of age are likely to develop CKD during their lifetime, and the prevalence of CKD is expected to climb over the next 15 years. Current CKD management is variable and suboptimal, as categorizing the very heterogeneous CKD patient population into risk cohorts for purposes of appropriate treatment is inaccurate. Without accurate risk classification, many patients are over-treated, leading to wasted expenses and adverse events, while others are not identified in time to receive interventions that change the course of the disease.
A new algorithm has been created that predicts patients’ risk of renal failure based on a specific set of laboratory tests combined with patient age and gender. Validated by more than 720,000 patients spanning 30 countries, it can reliably predict a patient’s risk of experiencing renal failure requiring dialysis or transplant. Studies show that a lab-based analytics program that incorporates this algorithm with care protocols, dashboards, and educational patient reports can generate substantial savings and improved outcomes for ACOs and health systems.
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Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
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What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
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Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
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This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
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Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
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1. Chronic Kidney Disease
in Elderly
Adnan Naseer, M.D.
Assistant Professor of Medicine
Division of Nephrology
University of Tennessee, Memphis
2. Outline
Epidemiology of chronic kidney disease in
elderly
Aging and kidney
Outcomes in chronic kidney disease and
end stage renal disease in elderly
Management strategies in elderly with
chronic kidney disease
Palliative care and chronic kidney disease
3. The Graying of America
According to US Census Bureau projections, the
elderly population will more than double between
2000 and 2030, growing from 35 million to over 70
million.
Much of this growth is attributed to the "baby
boom" generation which will enter their elderly
years between 2010 and 2030.
Source of data: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005.
4. U.S. Population Pyramids
Source of charts: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005.
2000 2020 2040
5. The Oldest Old
The "oldest old" – those aged 85 and over – are
the most rapidly growing elderly age group.
The oldest old represented 12.1% of the elderly
population in 2000 and 1.5% of the total
population. In 2050, they are projected to be
24% of elderly Americans and 5% of all
Americans.
6. Increases in the Oldest Old
U.S. Population Aged 85+ (in millions)
0.2 0.3 0.4 0.6 0.9 1.5 2.2
3.1
4.2
6.1
7.3
9.6
15.4
20.9
0.2
0.1
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
2010
2020
2030
2040
2050
Sources of data: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005; U.S. Census
Bureau, U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin, 2004.
14. Prevalence of Moderate CKD by Age
Group (NHANES)
27%
37%
Coresh et al., JAMA 2007;298(17):2038-2047
15. Prevalence of CKD in U.S.
2000 Census
Thus, about 16 million Americans have a GFR less
than 60 mL/min/1.73 m2. Plus 10 million more have a
GFR over 60 but have persistent albuminuria.
Coresh, et al., 2007
GFR
(mL/min/1.73 m2)
59-30 29-15
Number of People 15.5 Million 0.7 Million
16. Prevalence of Low eGFR by Age Group Among US Veterans
Ann M. O’Hare et al JASN 2007
20. Aging Related Changes
Anatomic Changes
– Loss of renal mass; 10% reduction per decade. Wt of
kidney 400 g at 4th decade, 200 g at 8th decade.
– Glomerulosclerosis, predominantly cortical nephrons.
– Tubulointerstitial fibrosis.
Renal blood flow
– Progressive reduction in renal plasma flow from 600
ml/min to 300 ml/min by age 80.
21.
22. Effect of Age on eGFR
The “normal” eGFR is age-related
In normal “healthy” individuals, the eGFR will
fall by one percent for every year after 40
years of age
An 80 year old man will have an expected
eGFR of 50-60 ml/min
25. Baltimore Longitudinal Study
of Aging
1958-1981
446 volunteers age 22 to 97 years old
Observed decline of 8.0 ml/min per 1.73
m²/decade of life.
One third of subjects did not have decline
in GFR.
Lindeman RD et al., J Am Geriatr Soc 1985;33:278-285.
28. Adjusted Risk of Mortality for
eGFR <60 in adults >65 years
CKD Prognosis Consortium, Lancet, 2010
Adjusted for ACR Adjusted for Dipstick Protein
Reference: eGFR 95 ml/min
29. CKD leads to CVD
1.0
1.4
2.0
2.8
3.4
0.0
1.0
2.0
3.0
4.0
≥ 60 45-59 30-44 15-29 < 15
Adjusted
Hazard Ratio
for CVD Events
Go A, et al. NEJM 2004;351:1296-1305
eGFR ml/min/1.73 m2
30. Go A, et al. NEJM 2004;351:1296-1305
CKD and Risk of Death
31.
32. Age affects Outcomes in CKD
All patients with eGFR <60 in the year following
October 1, 2000 who had an additional eGFR
<60 in the previous 3 months
Creatinine and outcomes were followed for up to
4 years
209,622 veterans with stage 3-5 CKD
Mean age 73, 47% over 75
O’Hare , A. M. et al. J Am Soc Nephrol 2007;18:2758-2765
34. “Progression of kidney dysfunction in the
community-dwelling elderly”
All subjects > 66 years old, two years of follow-up
1% reached ESRD, of which 93 % came from group with eGFR < 30
Hemmelgarn et al, KI 2006
36. Risk Factors for Progression of CKD
Diabetes Mellitus
Hypertension
Proteinuria
Advanced CKD (eGFR <30 ml/min)
Male gender
Minority race
37. Which individuals with
abnormal eGFR should we
worry about?
Those with very poor kidney function for age
Those with deteriorating kidney function
Those who may have reversible/treatable cause
(unexplained proteinuria/hematuria)
Those with functional consequences of CKD
(anemia, renal bone disease, persistent
hyperkalemia)
38. Management of CKD
Few randomized control trials to support specific
management strategies
Most trials excluded or very few patients >70 years old
Results of RCTs may not be generalizable to older
patients
– Differences in progression of CKD, development of ESRD and
death
– Greater burden of co-morbidities, dementia, frailty
Current guidelines advocate “Age Neutral” approach
Care of elderly CKD patients should be individualized
and integrated with patient preferences
39. Therapeutic Intervention in
CKD
Advice to reduce cardiovascular risk
(weight, smoking, diet, lipids etc)
Tight BP control (more stringent target if
Proteinuria)
ACE-inhibitors & ARBs (check eGFR
and K+ 7-10 days later)
Anemia management
Bone disease
40. ESRD in Elderly
Frequent co-morbidities: CVD, malnutrition
Disabilities: physical, cognitive, hearing,
visual
Nursing home care
Higher mortality: mean survival for patients
older than 75 years on RRT is 31 months
41. Cumulative survival in two groups of hemodialysis patients: A represents
patients between 50 and 60 years old. B represents patients above 75
years old. January 1996 to December 2000.
Patients 50-60 yrs
Survival rates at 1
and 3 years 93%
and 74%
Survival in ESRD Patients Over 75 Years Old
Patients >75 yrs
Survival rates at 1
and 3 years 80%
and 45%
Leblanc et al. Am J Nephrol. 2003 Mar-Apr;23(2):71-7
42. Changes in Survival Among
Elderly ESRD Patients
CMAJ October 2007, Jassal et al, CORR data
43. Dialysis or not?
A comparative survival study of patients over 75
years with chronic kidney disease stage 5
Retrospective analysis of 129 patients , Follow-up ~570 days
Murtagh et al, Nephrology, Dialysis Transplantation 2007
44. Survival With and Without Dialysis
Murtagh et al, Nephrology, Dialysis Transplantation 2007
45. Kaplan-Meier survival curves in high co-morbidity only patients
Murtagh et al, Nephrology, Dialysis Transplantation 2007
48. Age as Risk Factor for Death
3-4% increase in death rate for each one year
increment in age beginning at age 18.
2011 USRDS Annual Data Report
49. Malnutrition and ESRD
Relative risk of mortality and quartiles of serum albumin.
Adjusted for baseline albumin (A), ∆albumin (B)
Pifer et al. DOPPS Kidney Int 2002;62(6):2238-45
50. Functional Status and ESRD
Poor functional status is highly predictive of early
death (RR 1.5 to 3.0)
Measures of functional status
– Ability to ambulate (yes/no)
– Karnofsky scale
– Activities of daily living
Inability to transfer and falls are indicators of poor
prognosis
51. Comorbiditiy and ESRD
DM, CHF, CAD, PVD, COPD, malignancy
Comorbidity scores
– Charlson Comorbidity Index
– ESRD (Modified Charlson) Comorbidity Index
52. Adapting Charlson Comorbidity
Index for ESRD Patients
(A) ESRD Comorbidity
Index score
(B) Charlson Comorbidity
Index score
Kaplan-Meier Survival
Plots
Hemmelgarn et al. AJKD, 42(1), 2003: 125-32
53. The “Surprise” Question
“Would I be surprised if this patient died
in the next 12 months?”
Moss et al. Clin J Am Soc Nephrol; 3: 1379-84, 2008
54. Predicting Who Will Die Within
First Year on Dialysis
– An integrated mathematical prognostic model
takes into account:
– Clinician’s estimate of prognosis
– Laboratory values
– Comorbidities
– Functional status
55. HD Mortality Predictor
Mathematical model for estimating patient
survival at 6 months using
– The “Surprise” question
– Serum albumin
– Age
– Presence or absence of dementia and PVD
http://touchcalc.com/calculators/sq
Cohen et al, Clin J Am Soc Nephrol 2010; 5(1):72-9
56.
57.
58. Palliative Care
Definition
Palliative care is comprehensive,
interdisciplinary care of patients and
families facing a chronic or terminal
illness focusing primarily on comfort and
support.
Billings JA. Palliative Care. Recent Advances. BMJ 2000:321:555-558.
59. Aspects of Palliative Care
Pain and symptom management
Advance care planning
–DNR
–Advance Directives
Psychosocial and spiritual support
60. When is Palliative Care Needed?
Around the decision to stop dialysis
At the onset of conservative management
When symptoms from co-morbid conditions
are severe
At times of crisis e.g. new diagnosis of
malignancy, or acute severe symptoms
Patients who develop renal failure as a
consequence of other life threatening
conditions or its treatment e.g. cancer
61. Criteria for Withholding Dialysis
Patient or surrogate wishes
Profound neurologic impairment
– Persistent vegetative state, stroke, dementia
Non-renal terminal condition
– Malignancy, end-stage liver, heart, lungs
Medical condition that precludes process of
dialysis
Age, per se, is not a criterion to withhold dialysis
64. Recommendations
1. All members of the renal health care team including
nephrologists, nephrology nurses, nephrology social
workers, and renal dietitians should obtain education
and skills in the principles of palliative care to ensure
that ESRD patients and families receive
multidimensional, compassionate, and competent care
at the end of life.
RPA/ASN Statement on Quality Care
at the End of Life
65. RPA/ASN Statement on Quality Care
at the End of Life
2. In responding to an ESRD patient/surrogate decision
to forgo dialysis, the nephrologist is obligated to
determine, if possible, why the patient/surrogate has
decided to forgo dialysis … Once the nephrologist is
satisfied that the patient’s decision to forgo dialysis is
informed and uncoerced, the nephrologist should
respect the wishes of the patient/surrogate.
66. 3. After a decision is made to forgo dialysis, the renal
team should refer the patient to a hospice or adopt
a palliative care approach to patient care. In either
case, the nephrologist and other members of the
renal team should remain active in the patient’s
care to maintain continuity of relationships and
treatment.
RPA/ASN Statement on Quality Care
at the End of Life
67. 4. Nephrologists and other members of the renal
team should obtain education and skills in advance
care planning so that they are comfortable
addressing end-of-life issues with their patients.
RPA/ASN Statement on Quality Care
at the End of Life
68. Exposure to Palliative Care
Geriatrics Critical
Care
Nephrology
Completed a Rotation
Focused on Palliative Care
71% 2% 1%
Had Contact with Palliative
Care Specialist
80% 46% 45%
Quality of teaching with
respect to end-of-life care
rated ‘very good’ or
‘excellent’
53% 34% 15%
Holley et al. Am J Kidney Dis 42(4):813-820, 2003.
69. Amount of Training to Manage a
Dying Patient
0%
10%
20%
30%
40%
50%
60%
0-3 4-7 8-10
0=No Training 10=A Lot of Training
Geriatrics
Pulmonary/ Critical Care
Nephrology
71. Cont’d
This patient is likely to have a
cardiorenal syndrome
Evidence of progression?
– if not, conservative management
– if so, is there any prospect of reversibility
(in this case probably not) or would the
patient tolerate/ benefit from renal
replacement therapy (in this case probably
not)
Palliative care pathway
72. Summary
Assess risk for CKD progression
– Serial eGFR
– Proteinuria and other risk factors
Assess CV risk
– As per high risk group guidelines
Assess for CKD complications
– Anemia
– Bone disease
– Malnutrition
Assess for renal replacement VS Non-dialytic therapy
Assess for palliative care