The document discusses chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the geriatric population, highlighting definitions, measurements, risk factors, and management goals. It notes a rising prevalence of CKD with age, particularly among diverse racial groups and those with comorbidities such as diabetes and hypertension. The document emphasizes the importance of nephrology referral, management of complications, and trends in renal replacement therapy (RRT) outcomes, especially in older adults.

1. CKD5/ESRD
Geriatric Population
26 Feb 2013
Amy Yau, MD

2. Definition / Measurement
• Proteinuria
• Serum Cystatin C
– Better prediction of mortality and
CV disease
• Cockcroft-Gault
– Overestimates GFR more than
MDRD
75% calculations within 30% of
measured GFR
• MDRD
– Better with diabetic kidney
disease (GFR <60)
90% calculations within 30%
measured GFR
Falsely Low GFR
- Vegetarian diet
- Unilateral kidney
- Low ECF (heart failure, cirrhosis)

3. Incidence / Prevalence
• >70 yo: More than
25% with CKD3+
• >75 yo: 1:3 new ESRD/
CKD5 related to DMII
Prevalence of CKD
• Will increase from
9% in 2000 to
16% in 2050

4. Causes
• Age, Race, Family History
– African-Americans x3.8
– Native Americans x2.0
– Asians x1.3
• HTN, DMII, Hereditary Diseases
• Obesity
• Vascular disease (changes in glomeruli)
– Changes in glomeruli
– RAAS system less active (low concentration
of renin, aldosterone)
– Artery stiffness
• Cellular changes (telomeres)
• Low renal mass

5. Risk Factors for Progression
Obesity
• increased glomerular
hyperfiltration
• increased glomerular HTN
• low renal plasma flow
• worsening albuminuria
Nephrotoxins
• Tobacco, EtOH
• Recreational drugs
• radiocontrast
Age
Recurrent AKI

6. Progression
• Natural Rate of Decline (mean)
0.75-1 mL/min/1.73 m2 per year
• 30% adults >70 yo with GFR <60 cc/min will stabilize
Risk Factors for Progression:
Age (GFR when risk of progression > risk of death)
– 18-44 yo GFR 45
– 65-84 yo GFR 15
– > 85 yo GFR n/a risk of death >>>> risk of progression to ESRD

7. Goals for Providers
• Referral to Nephrology
• Management of Complications / Dialyzability of Medications
– HTN goal <130/80
ACEi/ARB with proteinuria >200 mg protein/g Cr
– Anemia goal HgB 10-12, max 13
Iron deficiency (Fe Sat >20%, ferritin >100), low
<40
Need for Epogen (< HgB 9.0)
– Mineral Bone Disease
– DMII goal HbA1C <7.0 (lower in younger patients)
– Cardiovascular (CVA, CAD, PVD) Risk Reduction
vascular calcifications, oxidative stress, homocysteinemia
– Electrolytes / Acidemia (start bicarb once 22)
– Uremia / Pruritis / Pain
– Malnutrition

8. RRT
• 1996 – 2003: adjusting to population growth….in 80-90 yo adults…
– Initiation of dialysis rate increased by 57%
• Related to earlier initiation
• More services/access
• Referral:
– (Australia) 8.8% patients with CKD (any stage) referred
mean GFR 27 +/- 14.2 cc/min
– (United States, 2007) 43% new ESRD patients had NOT seen
Nephrologist prior to initiation
• Peritoneal Dialysis
• Hemodialysis (home or at center)
– Nocturnal
– Intermittent (daily or three times a week)

9. Transplantation
• 5-6 x more likely to receive deceased donor transplant (>70 yo)
• Improved QoL at lower cost compared to RRT
• Improved survival (despite mortality risk at time of surgery)
– >70 yo
• 41% lower mortality risk
• 53% lower mortality risk in diabetic subgroup
– >65 yo
• 1 yr survival 90 %
• 3 yr survival 77 %
• 5 yr survival 62 %
Benefits over RRT decline as patient ages

10. RRT: Patient Selection
Of 844 pts (>75 yo)
• RRT
– 689 patients (82%)
– Avg age 58 +/- 15 yo
– 17% with large comorbidites
• CMM
– 155 patients (18%)
– Avg age 77 +/- 6 yo
– 49% with large comorbidities

11. • 80-90 yo TOTAL one year survival compared to peers:
46%
• Compared to 80-84 yo
– Risk of death 22% higher (85-89 yo)
– Risk of death 56% higher (>90 yo)
Age (yo) Peers (mo survival)
Not CKD
RRT (mo survival)
65-79
75-79 10.4 yr (2.6 yr with CKD)
24.9 mo
80-84 105 mo 15.9 mo
85-89 78 mo 11.6 mo
90-94 57 mo 8.4 mo
RRT: Survival Benefit?
Compared to Peers

12. RRT: Survival Benefit?
Compared to CMM
• >80 yo Compared to CCM*
– 28.9 mo survival (RRT)
– 8.9 mo survival (CCM)
Wong et al. Renal Failure 2007

14. RRT: Survival Benefit?
With Comorbidities
Comorbidity Score (Charleston, Davies): http://touchcalc.com/calculators/cci_js
• Compared to 0-1 Comorbidities Charleston
– 2-3 31% increased r/o death
– 4 68% increased r/o death
• >75 yo Davies
– >2 comorbidities no change in survival
– <2 comorbidities improvement in mortality by half
RRT (mo survival) CMM (mo survival)
<75 yo >75 yo <75 yo >75 yo
69.6 25.1 33.0 15.5
Low comorbidity
non DMII
72.5
74.4
36.8
24.4
33.0
52.8
29.4
18.1
High comorbidity *
(not significant)
26.0 17.4

16. Fig. 3. Cox proportional
model survival curve of
patients aged >75 years -
CM vs RRT - adjusted for
age, gender, ethnicity, the
presence of diabetes and
the presence of high
comorbidity. Median
survival in RRT patients is
better by <4 mo, which is
not statistically significant
(P=0.43)

17. RRT: QoL
CMM: 10-16 days per year
RRT: 20-35 days per year
Less than General Population
Similar to CMM

18. CMM: QoL

19. References
• Munikrishnappa. Chronic Kidney Disease in the Elderly - a Geriatrician's Perspective. 2007
• Williams et al. Kidney Disease in Elderly Diabetic Patients. ASN. 2009
• Jenette. Geriatric Nephrology: Research, Policy, & Practice. UNC Kidney Center PPT. 2011.
• Verma. Kidney Disease and Hypertension in Geriatric Population. Penn STate Hershey Medical Center PPT.
• O'Hare. Hypertension, Chronic Kidney Disease, and the Elderly. ASN. 2009
• Murtagh et al. Symptoms in the Month Before Death for Stage 5 Chronic Kidney Disease Patients Managed
Without Dialysis. Journal of Pain and Symptom Management. 2010.
• Murtagh et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease
stage 5. NDT. 2007
• Kurella et al. Octogenarians and Nonageneraians Starting Dialysis in the United States. Ann Intern Med. 2007.
• Foote. Outcomes of dialysis in the elderly. The George Institute for Global Health PPT. 2011
• Eriksen et al. The Progression of chronic kidney disease: A 10 year population based study of the effects of
gender and age. ISN. 2006
• Chandna et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal
replacement therapy. NDT. 2010
• Boudville et al. Limited referral to nephrologists from a tertiary geriatric outpatient clinic despite a high
prevalence of chronic kidney disease and anaemia. BMC Geriatrics 2012.
• Anderson et al. Predision, Progression, and Outcomes of Chronic Kidney Disease in Older Adults. JASN. 2009
• Taal et al. Predicting initiation and progression of chronic kidney disease: Developing renal risk scores. ISN. 2006