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The Elderly Patient and Peritoneal Dialysis

The Elderly Patient and Peritoneal Dialysis. Fredric O. Finkelstein Clinical Professor of Medicine Yale University New Haven, CT USA. Points to be Covered. Increasing number of elderly patients with ESRD Need to be clear about the goals and objectives of therapies

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The Elderly Patient and Peritoneal Dialysis

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  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 “Uremic” symptoms Fatigue Lethargy Cognitive impairment Neuropathy Uremic pruritus Sleep disorders Anorexia, nausea Restless leg syndrome • Pericarditis • Acute neurological problems • Metabolic problems • Unmanageable fluid overload

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

  14. 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) • 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

  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

  21. Prevalent Dialysis Patients: % on PD and HD USRDS

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

  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 Kadambi et al: Seminars in Dialysis 2002

  28. Technique and Patient Survival of Elderly on PDKadambi 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) * Infections per patient months a P < 0.05

  30. Group 1: 235 Patients age 75 or older Group 2: < 60 years of age

  31. New Haven Study: PD in the Elderly: QofL Data 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. 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 * 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 *Admissions/patient-year

  37. Adjusted Estimates of Outcomes HD v PD Harris S et al, PDI 2002

  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. New Haven Experience

  40. Family Dynamics Are Important 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

  41. 6:26-29, 1990. Percent Transfers attributed to Psychosocial Family Rating • Family dynamics scored with Beavers Timberlawn Evaluation scale • Cause of technique failure attributed by dialysis staff 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 family score

  43. 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 EXTENDED CARE FACILITIES AND CPD

  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

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