This document discusses challenges in applying clinical trial results for chronic kidney disease (CKD) to elderly patients. It notes that CKD is defined based on kidney structure/function abnormalities for over 3 months, assessed via estimated glomerular filtration rate and albuminuria levels. Frailty is common in CKD patients over 60 and associated with higher mortality and dialysis need. CKD is also linked to impaired cognition and physical function in older adults. However, clinical trials often exclude elderly patients, so guidance is largely based on younger populations. The document calls for more research accounting for frailty, function, and including more representative elderly patients.
Rotarians and Diabetes Prevention Developing Healthy Communities: Part 1 rag ...KouameK
he Rotarian Action Group for Diabetes is working to stop the global epidemic of the disease. Come learn how Rotarians can lead communities to better health and prevent children dying from lack of insulin. Learn about model programs of prevention and service that your club can institute to improve health in your own community.
Co-moderators:
C. Wayne Edwards, Past District Governor
Rotary Club of Tallahassee, Florida, USA
Larry C. Deeb, Member, The Rotary Foundation Cadre of Technical Advisers
Rotary Club of Tallahassee, Florida, USA
Rotarians and Diabetes Prevention Developing Healthy Communities: Part 1 rag ...KouameK
he Rotarian Action Group for Diabetes is working to stop the global epidemic of the disease. Come learn how Rotarians can lead communities to better health and prevent children dying from lack of insulin. Learn about model programs of prevention and service that your club can institute to improve health in your own community.
Co-moderators:
C. Wayne Edwards, Past District Governor
Rotary Club of Tallahassee, Florida, USA
Larry C. Deeb, Member, The Rotary Foundation Cadre of Technical Advisers
Rotary Club of Tallahassee, Florida, USA
Study of Barthel Score among CKD Patients Belonging from Tribal Areas in Tert...ijtsrd
Chronic Kidney Disease CKD is one of the independent diseases which can lead to sever disability and it is a major emerging public health concern worldwide because it often leads to poor patient outcome 1 . Some of the associated factor with impaired functional status with CKD patients has not been fully elucidated, but some traditional such as cardiovascular diseases hypertension, myocardial ischemia , cerebrovascular diseases, and diabetes mellitus as well as non-traditional factors such as malnutrition-inflammation syndrome and depression may involve. A cross-sectional and longitudinal study has shown that risk of low functional status is directly proportional to kidney impairment 2, 3 . Thus, individuals with chronic kidney disease CKD have 40-70 higher risk of functional limitation than those without CKD 4 . In one study to assess the functional status of the CKD patients by using Barthel index found that 50 patients were dependent for the basic activities of daily life 5 In the current study, we hypothesize that there is a close relationship between the presence of CKD and the functional status of renal patients. We conducted this study with objective to assess the functional status of patients with Chronic Kidney Disease by using Barthel Index as a assessment tool on patients who were admitted under Nephrology Unite of Dr. B.R.A.M Hospital Raipur, CG. Dr. Dolly Ajwani Ratre | Rashmi Nande | Navin Kumar Ratre "Study of Barthel Score among CKD Patients Belonging from Tribal Areas in Tertiary Care Hospital, Chhattisgarh" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-2 , February 2019, URL: https://www.ijtsrd.com/papers/ijtsrd20266.pdf
Paper URL: https://www.ijtsrd.com/medicine/other/20266/study-of-barthel-score-among-ckd-patients-belonging-from-tribal-areas-in-tertiary-care-hospital-chhattisgarh/dr-dolly-ajwani-ratre
Study of Barthel Score among CKD Patients Belonging from Tribal Areas in Tert...ijtsrd
Chronic Kidney Disease CKD is one of the independent diseases which can lead to sever disability and it is a major emerging public health concern worldwide because it often leads to poor patient outcome 1 . Some of the associated factor with impaired functional status with CKD patients has not been fully elucidated, but some traditional such as cardiovascular diseases hypertension, myocardial ischemia , cerebrovascular diseases, and diabetes mellitus as well as non-traditional factors such as malnutrition-inflammation syndrome and depression may involve. A cross-sectional and longitudinal study has shown that risk of low functional status is directly proportional to kidney impairment 2, 3 . Thus, individuals with chronic kidney disease CKD have 40-70 higher risk of functional limitation than those without CKD 4 . In one study to assess the functional status of the CKD patients by using Barthel index found that 50 patients were dependent for the basic activities of daily life 5 In the current study, we hypothesize that there is a close relationship between the presence of CKD and the functional status of renal patients. We conducted this study with objective to assess the functional status of patients with Chronic Kidney Disease by using Barthel Index as a assessment tool on patients who were admitted under Nephrology Unite of Dr. B.R.A.M Hospital Raipur, CG. Dr. Dolly Ajwani Ratre | Rashmi Nande | Navin Kumar Ratre "Study of Barthel Score among CKD Patients Belonging from Tribal Areas in Tertiary Care Hospital, Chhattisgarh" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-2 , February 2019, URL: https://www.ijtsrd.com/papers/ijtsrd20266.pdf
Paper URL: https://www.ijtsrd.com/medicine/other/20266/study-of-barthel-score-among-ckd-patients-belonging-from-tribal-areas-in-tertiary-care-hospital-chhattisgarh/dr-dolly-ajwani-ratre
In an endeavour to keep patent enthusiasts abreast with the latest patent related activities in leading geographies, we provide a weekly update of patent cases filed in the US. Go ahead, download the compilation for free!
Patent Office in India publishes patent and design registration information on a weekly basis (on Friday each week). This is public notification, enabling the public to take appropriate action if desired. Data published on August 28th, 2015. Data sourced from Indian Patent Office website by InvnTree IP Service Pvt Ltd, a patent services company based in Bangalore
In an endeavour to keep patent enthusiasts abreast with the latest patent related activities in leading geographies, we provide a weekly update of patent cases filed in the US. Go ahead, download the compilation for free!
In an endeavour to keep patent enthusiasts abreast with the latest patent related activities in leading geographies, we provide a weekly update of patent cases filed in the US. Go ahead, download the compilation for free!
Patent Office in India publishes patent and design registration information on a weekly basis (on Friday each week). This is public notification, enabling the public to take appropriate action if desired. Data published on January 22nd, 2016. Data sourced from Indian Patent Office website by InvnTree IP Service Pvt Ltd, a patent services company based in Bangalore
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)
Geriatric Nephrology (changes in renal physiology, Chronic Kidney Disease, Advanced Care Planning for the elderly patients with CKD, pharmacotherapy of common medical problems in the older individual with chronic kidney disease)
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Prof. Mridul Panditrao
Prof. Mridul M. Panditrao tries to explain the pros and cons about the good strategy, whcih became controversial and almost obsolete. He also tries to tract the whole aspect of the phenomenon and reviews/ RCTs/
Strict (Tight) Glycemic control (SGC/TGC), as it is called, was and still is a good strategy. It can be defined as maintenance of the blood glucose level in the range of 80-110 mg /dl. with help of dose variable and intensive insulin therapy (IIT). Since its introduction, there have been conflicting reports of its efficacy and complications. This resulted in slow but steady neglect of this very good idea leading to its almost complete demise.
An effort has been made in this review, to impartially analyze all the available evidence and try to find the reasons for the negative publicity which led to the neglect or worse still, the wrong use of this protocol. Some suggestions for fair and proper implementation of the strategy are put forward.
etc/
Disparity of Interstitial Glucose for Capillary Glucose in Dialysis Diabetic ...semualkaira
The prevalence of chronic kidney disease (CKD) has steadily increased and diabetes is now considered the leading cause of endstage kidney disease (ESRD). Glycemic control in chronic renal
patients on dialysis presents additional difficulties because both
uremia and dialysis can affect insulin secretion and tissue insulin
sensitivity
Similar to Eama presentation nicolas martinez velilla avila 2015 final (20)
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Eama presentation nicolas martinez velilla avila 2015 final
1. Major difficulties and pitfalls for the
application of clinical trial results in an 85-
year old patient:CHRONIC KIDNEY DISEASE
NICOLAS MARTINEZ VELILLA
COMPLEJO HOSPITALARIO DE NAVARRA
PAMPLONA. SPAIN
2. OUTLINE
1. Definition and staging
2. Diagnosis and overdiagnosis
3. Some special features in the elderly
Frailty, function, cognition
4. Treatment and clinical trials
5. THM
3. 1. Definition
• CKD is defined as abnormalities of the kidney
structure or function, present for >3 months,
with implications for health
• It largely relies on 2 laboratory measures:
– An estimate of Glomerular Filtration Rate (eGFR),
based on creatinine or cystatin levels
– An assessment of kidney damage, derived from a
range of tests, most commonly, increased albumin
in the urine (albuminuria)
7. From: Glomerular Filtration Rate and Albuminuria for Detection and Staging of Acute and Chronic
Kidney Disease in Adults: A Systematic Review
JAMA. 2015;313(8):837-846. doi:10.1001/jama.2015.0602
8.
9. 3. CKD and Frailty
• Associated with all stages of CKD and particularly
from the moderate to severe stage Am J Med 2009
• Prevalence of frailty in CKD: 75% of age >60 years
(largest study for prevalence of frailty in dialysis
population) Am Soc Nephrol 2007
• Patients are 2.5 times more likely to die or to have to
start dialysis during follow-up Am J Kid Dis 2012
• Potential to improve the identification of patients at
risk for adverse frailty-associated outcomes and
these patients might benefit from interventions Am
Soc Nephrol 2007
• Frailty Index (score based on 70 components of
health) excludes renal disease!!
10.
11. 3. CKD, function and cognition
• Impaired cognitive function and ph
ysical perfomance are important
factors impacting the lives of
people with CKD Curr opin nephrol
hypertens2014;23:291-7 J Gerontol A Biol Sci Med
Sci 2014;69:315-22
• CKD is a significant independent
somatic risk factor in the
development of cognitive decline.
Am J Nephr 2012;35:474-82
• In individuals with CKD, higher
serum cystatin C levels were
associated with worse cognition
JAGS 2014
12. Interactions among eGFR, anemia, and mobility limitation define
different profiles of risk in older patients discharged from acute care hospitals
13. 4. Treatment and clinical trials
• Older patients are under-represented in clinical trials
• Current clinical practice guidelines focus on specific
diseases and often fail to overtly take into
consideration the presence of comorbid conditions
• Overall, there are no specific evidence-based
guidelines available for the treatment of CKD in the
elderly, particularly adults over 70 years of age, and
guidelines are based on evidence obtained from
younger populations
14. 4. Treatment and clinical trials
• The Ramipril Efficacy In Nephropathy study,63
which assessed
ramipril in patients with CKD 18–70 years
• The Program for Irbesartan Mortality and Morbidity Evaluation
study assessed irbesartan in diabetic nephropathy: 30–70 years.
• Hypertension (KDIGO): ungraded (based on expert opinion rather
than evidence)
• Salt restriction RCT <79 years
• Anemia: erythropoiesis-stimulating agents have not included the
elderly, particularly those over 75 years
• Bicarbonate therapy: mean age 51 years
15. MANAGEMENT OF ESRD
• >65 years are the most rapidly increasing group of the
ESRD population: substantial increase in the number of
elderly patients accepted onto dialysis
• 1-year survival for patients >80 years starting
hemodialysis was 48% (25% for nursing home
residents). Careful assessment, determination of
prognosis (CGA), considering adapted frailty criteria Arch
Intern Med 2012 Nat Rev Nephrol 2011
• Burden of dialysis may be high for geriatric patients
(QOL, functional status, life expectancy). Uncertanties
between benefits & harms
16. THM: More research is needed!
– Risk of overdiagnosis (staging, GFR)
– The concepts of frailty, cognitive and functional
impairment should be included in CKD
– Older participants representative of those seen in
clinical practice must be included in clinical trials
to better understand the benefits and potential
adverse effects of new drugs in the elderly
population
Editor's Notes
Renal insufficiency, renal impairment and renal failure
GFR is one component of excretory function, but is widely accepted as the best overall index of kidney function
- Modifications followed, with 2012 guidelines dividing stage 3 (eGFR 30-59) into 3A (30-44) and 3B (45-59) and adding three extended categories for persistent albuminuria
- Both low eGFR and high albuminuria were independently associated with mortality and ESRD regardless of age
- The severity of chronic kidney disease (CKD) significantly predicts mortality.The risk of death dramatically increased for every 15 mL decrease in glomerular filtration rate (GFR) below 60 mL/min/m21 1.
Acute and chronic kidney diseases are common and can be detected by simple and inexpensive laboratory tests Glomerular filtration rate (GFR) and albuminuria are the main kidney measures used for detection and stagingof acute and chronic kidney disease (GFR is a measure of kidney function; albuminuria is a marker of kidney damage)
- Initial tests include serum creatinine to estimate GFR and urine albumin-to-creatinine ratio in an untimed “spot” urine collection to estimate albuminuria. GFRcannot be measured directly; it can be assessed from clearance measurements or estimated from serum levels of endogenous filtration markers such as creatinine or cystatin
- Confirmatory tests should be performed for clinical decision making if there is uncertainty about the accuracy of initial tests Confirmatory tests for GFR include serum cystatin C with or without creatinine to estimate GFR or clearance measurements Confirmatory tests for albuminuria include albumin excretion rate in a timed urine collection
The elderly and the very old deserve careful analysis before they are labelled as having a chronic disease based solely on a single laboratory measurement,
Concern has arisen that this approach incorrectly labels individuals, particularly older persons, as having CKD, thus inflating the prevalence of a generic CKD in the aging population the eGFR criteria used in these classifications have led to the medicalization This phenomenon of medicalization has inevitably led to millions of older, and seemingly otherwise healthy, individuals to be inappropriately labeled as having CKD, and claims that an astonishing 40% to 50% of the US population is predicted to develop this disease in their lifetime,mostly at an advanced age
the most common category of CKD detected in community-based programs is 3A (at least a third of the people who meet the new definition) which predominantly affects older persons and is seldom progressive (around three quarters of these have no urine markers of kidney damage)
The current definitions may misclassify at least 30% of elderly people as having stage 3 disease . Thousands of people with stage 3A disease may need to be treated to prevent one case of end stage disease
- These studies suggest a direct relationship between kidney disease severity and frailty, and further that frailty in CKD has prognostic significance beyond standard comorbidity
- eGFR needs to be adjusted for muscle mass/physical performance when estimating kidney function in people aged 90 or more. Adding eGFR to the frailty model could significantly improve the predictive ability of frailty in older people. Frailty may be a common pathway of aging and CKD that may induce disability and that can be prevented by a multidimensional approach
- The frailty index is a score based upon the total number of deficits from a list of 70 componentes of health- interestingly the list excludes renal disease!
The existing evidence supports the conclusión that CKD is a model of accelerated aging, manifested by higher risks for por physic al function, frailty, and cognitive decline. A better understanding of these associations may lead to the identification of novel pathways to prevent the development of disability and dementia in older adults
Interactions among eGFR, anemia, and mobility limitation define different profiles of risk in older patients discharged from acute care hospitals, which deserve to be considered to identify patients needing special care and careful follow-up after discharge. Evidence suggests that CKD, anemia, and physical performance could interactively affect survival of older persons.
it is not necessarily valid to extrapolate risk–benefit ratios from younger adults to geriatric populations in the absence of evidence.
More than 50% of older adults have 3 or more chronic diseases and 20% have 5 or more. Seventy-four percent of people with kidney disease had 4 or more chronic diseases
Guidelines for people with CKD, diabetes, and cardiovascular disease do not recommend NSAID therapy, but those for osteoarthritis and low back pain do,26-29 and these are common conditions in older adults. A large case-control study (500,000 patients followed up for a mean of w6 years) examined the risk of AKI in people receiving either double therapy consisting of an NSAID combined with a diuretic or an NSAID with RAS blockade or triple therapy with a diuretic, an NSAID, and RAS blockade
- These trials formed the basis of evidence translation for the use of ACE inhibitors and ARB therapies in CKD. Therefore, there is a need for clinical trials that include older patients to assist in establishing therapeutic guidelines in this group.
-
Many older patients may benefit from dialysis (cogntive and functional status)
The best timing of dialysis initiation has been investigated. Early initiation may be harmful and is certainly of no advantage Arch Intern Med 2011 N Engl J Med 2010
“Fistula First” dialysis vascular access, which is practiced in younger patients, may not be the preferred approach for older patients because of their reduced life expectancy
Clinical trials in the dialysis population have often excluded the elderly, particularly those over 75 years
Importance of CGA, use of risk scores, assessment of nutritional status (multidisciplinarity)
Different treshold for the elderly
Age calibration does not solve the problem of needing to categorize continuous values of GFR and albuminuria for disease definition and classification. Indeed, age calibration will require even more categories based on the combination of age, GFR, and albuminuria.
Age calibration is too complicated and would require another term for decreased GFR or increased albuminuria that is not normal but not sufficient for the diagnosis of CKD. In the past, the terms “renal impairment” or “renal insufficiency” were used without definition, leading to the state of “chronic renal confusion.”
Age calibration could create the possibility that a patient’s disease classification could change because of age without a change in health status.
Age calibration does not change major treatment recommendations: they are based on the level of GFR and albuminuria, rather than the diagnosis of CKD. Examples include drug dosing of antibiotics or chemotherapy and contraindications to toxic agents such as nonsteroidal anti-inflammatory drugs and radiographic contrast based on GFR, and antihypertensive therapy with angiotensinconverting enzyme inhibitors and angiotensin II receptor blockers
based on albuminuria.
Age calibration is not well suited to address different risk relationships for different outcomes and covariate patterns in individual patients. Risk assessment tools are preferred for this purpose. In addition, age calibration does not address the issues that are important to patients.
- The CKD diagnostic approach that uses an absolute, single (not calibrated by age), arbitrary threshold of GFR and estimated GFR of less than 60 mL/min/1.73 m2 as disease defining fails to clearly distinguish the common age-related decline in kidney function (most likely physiological organ senescence) from that of more progressiveCKDdue to intrinsic renal diseases. Consequently, the most common category of CKD detected in community-based programs is 3ª (GFR of 45-59), which predominantly affects older persons and is seldom progressive (there are only 0.6 to 0.8 cases of ESRD per 1000 patient years in patients &gt;65 years) in the absence of significant proteinuria.
- The eGFR criteria used in these classifications have led to the medicalization of the common process involving organ functioning with aging; namely, the slow and inexorable decline in function, including that of the kidney. the hazards of all-causemortality appear to increase at around an eGFR of 60 mL/min/1.73 m2 regardless of age5; however, this observationmay be due to the selection of an inappropriate reference group. Age is clearly a modulating factor in risk associated with changes in eGFR
These issues can be adequately addressed by a simple age-adjusted revision in the diagnostic criteria for CKD. The threshold for defining CKD category 3ª should be adjusted to less than 45 mL/min/1.73m2. This adjustment would only be applicable to those who do not have any other corroborating signs of kidney disease such as proteinuria. Adoption of this change could make the CKD diagnostic and classification systems much less discriminatory toward the ever-expanding older component of the global population.
GFR is usually estimated from serum concentrations of a marker of filtration using GFR estimating equations
The reference range for creatinine considered as nor-mal in the healthy young is inappropriately high in the elderlyand serum values in the upper normal range may underlie earlyrenal dysfunction. In 20 years old individu-als a creatinine value of 1 mg/dL may correspond to an estimated GFR of 120 mL/min while the same value in 80 years-old persons might reflect an eGFR of 60 mL/min
The KDIGO guideline did not explicitily recommend a specific formula but the discussion tended to recommend the new Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI).
The CKD-EPI formula estimates mGFR with greater accuracy than other estimating formulas, especially in the physiological range, but we do not yet have a nomogram of the measurement in large numbers of healthy individuals across the age spectrum 20–80 years.
Controversies
In oldd subjects GFR is systematically underestimated by the Cockcroft-Gault formula The Modificationof Diet in Renal Disease (MDRD) MDRD equation is generally con-sidered more accurate than the CG to estimate GFR in old people(Levey et al., 2003). However, like the CG formula, the MDRDequation has not been specifically validated in the elderly. In a study involving 100 individuals aged 65–111 years no correla-tion was found between the two formulas. In the elderly cohort of the InCHIANTI study, creati-nine clearance &lt;60 mL/min calculated by the CG formula predictedall cause and cardiovascular mortality while the MDRD formula did no.
The Berlin Initiative Study (BIS)-1 (creatinine-based) and the BIS-2(cystatin-based), have been recently developed in a cohort of 610 individuals aged 70 years or older with no or mild-to-moderately reduced kidney function (GFR &lt;60 mL/min/1.73 m2). Interestingly, the BIS-2 equation yields the smallest bias followedby the creatinine-based BIS-1 and Cockcroft–Gault equations, while all the other formulas overestimate to an important extent thegolden standard. These formulas are of obvious relevance butstill lack external validation in other cohorts and, most impor-tantly, in different ethnicities.
The BIS1 equation was chosen because it showed the lowest deviation from the measured glomerular filtration rate and the smallest misclassification rate among creatinine-based). Additionally, a recent study comparing the accuracy of BIS1, MDRD, and CKD-EPI in older patients showed that BIS1 was the most reliable for assessing renal function in older white patients, especially in those with CKD stages 1–3 The BIS1 equation has been shown to be more accurate than Modification of Diet in Renal Disease (MDRD) and CKD-EPIderived measures in predicting measured GFR. Additionally, BIS1 equation is the only method specifically developed in a population older than 70 years
Has the smalleste misclasssification, The BIS1 equation has been shown to be more accurate, is the only method specifically developed in a population older than 70 years
Confusion is the unintended consequence of guideline proliferation.6 In the 12 years since publication of the first internationally accepted definition and classification of CKD,7 there have been 2,638 peer-reviewed guidelines published relating to cardiovascular disease; 728, to older people (age &gt; 65years); 529, to diabetes; and 523, to kidney disease
