This document discusses dialysis in elderly patients. It notes that biological age is more important than calendar age when evaluating elderly patients for dialysis. Initiation of renal replacement therapy requires consideration of comorbidities, mental status, quality of life, life expectancy, vascular access, and socioeconomic factors. Dialysis in elderly patients is associated with higher rates of comorbidities like atherosclerosis and fewer vascular access options. Conservative care without dialysis is an alternative for some elderly patients with multiple comorbidities. Quality of life assessments are important when considering dialysis for elderly patients.

1. Dialysis in Elderly
World Kidney Day 2014
Kalba
Dr. Muhamed AL Rohani, MD, FISN

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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:

20. 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

21. Withdrawal of Dialysis – Third Leading
Cause of Death
• Shared decision making
• Informed consent
• Estimate prognosis
• Advanced directives
• Time limited trials
• Palliative care
RPA/ASN