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Chronic disease management in older people with advanced CKD

Chronic disease management in older people with advanced CKD. Shelagh O’Riordan Consultant Geriatrician and BGS representative on recent NICE CKD guidelines. What I will be talking about:. The approach to CKD as a geriatrician Diagnosis and classification of CKD Anaemia Bones Acidosis

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Chronic disease management in older people with advanced CKD

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  1. Chronic disease management in older people with advanced CKD Shelagh O’Riordan Consultant Geriatrician and BGS representative on recent NICE CKD guidelines

  2. What I will be talking about: • The approach to CKD as a geriatrician • Diagnosis and classification of CKD • Anaemia • Bones • Acidosis • Heart failure • Summary

  3. Frailty and CKD • Frailty very common in CKD (more so than those without) • Functional impairment • Cognitive impairment- even younger patients with moderate CKD have measurable cognitive impairment • Older people more influenced by potential for side effects of treatment than potential risk reduction • Are renal physicians actually geriatricians? • Are geriatricians actually partly renal physicians?

  4. Mrs A • 76 y o woman • CKD stage 4, severe OA, hypertension, diabetes • GFR 25-30, 2+ protein on urine dip, BP 145/90 • Difficulty getting out of chair, especially at the end of the day • Family live nearby but has difficulty getting out of the house to be involved in their lives • Codeine based analgesia cause severe constipation • Asks if she can take NSAIDS for her knee pain

  5. Do we have a different perspective? Disease orientated approach Person orientated approach Comprehensive geriatric assessment (CGA) Acknowledge conflicting priorities with NSAID use Consider other options eg therapy, assistive devices, other analgesia If really can’t cope without NSAIDS, change ACEI to different antihypertensive agents Goal of treatment- what matters most to patient, preserving independence, planning for the future • History related to kidney function- oedema, BP etc. Assess progression and CVD risk • Increase ACEI for BP control as high risk CVD and progression • Assess knee pain likely not to be related to kidneys • Use of NSAIDs likely to worsen function • Goal of treatment- preserve renal function, reduce CVD risk

  6. Diagnosis of kidney disease

  7. The debate rages on…… Age calibrated classification of CKD Continue with current classification CKD is commoner in older people- so is hypertentsion, diabetes, hyperlipaemia- all increase risk of CVD Not a consequence of normal aging- wide variation in eGFR and protein Low eGFR and high protein excretion related to higher mortality Age calibration will be too complicated • Doesn’t take into account normal aging • Incorrect labelling of older people with CKD- overdiagnosis • 40-50% of the population will develop CKD in their lifetime! • Suggests a new classification for older people starting at eGFR of 45

  8. Did NICE CKD 2014 tackle this issue? • Use creatinine based equation CKD-EPI • If eGFRcreatinine 45-59 and no other signs of CKD, do an eGFRcystatinC • Do not diagnose CKD in people with: • •an eGFRcreatinine of 45–59 ml/min/1.73 m2 and • •an eGFRcystatinC of more than 60 ml/min/1.73 m2 and • •no other marker of kidney disease • Significant proportion of older people with very low risk of problems from CKD removed from the “CKD List”

  9. Updated categories of CKD

  10. Anaemia in CKD • Managing renal anaemia improves QOL • May have a role in treatment even for very frail patients • Investigate if Hb<110g/L or symptomatic • Diagnose iron deficiency and treat first but if target Hb not reached after 6M consider referral • IV iron to keep %hypochromic red cells <6% • Epo to keep Hb 100-120g/L • Trial of treatment- stop if not improving symptoms.

  11. Renal bone disease and osteoporosis • Significant increase in hip fracture if eGFR<60 • In men 50-74y 3x increase CKD in those with hip fracture than those without • High risk hip fracture if on dialysis • Difficult to treat

  12. Treatment options for osteoporosis in CKD • Diagnose vitamin D deficiency in same way you normally would • Use 1-alpha hydroxylated vitamin D if eGFR <30mmol/l and monitor calcium • Use oral bisphosphonates if eGFR >30mmol/l • Only use IV zoledronic acid if eGFR>35ml/min/m2and clinically indicated • Can use denosumab if eGFR <30 but not if on dialysis or eGFR<15- high risk of hypocalcaemia • Don’t forget your best treatment might be falls prevention!!

  13. Should we treat metabolic acidosis in older people? Advantages Disadvantages Bulky, difficult to take tablets- 3/d Increase sodium load- fluid retention, increase BP GI side effects No evidence improves quality of life • Metabolic acidosis common in advanced CKD • Leads to muscle weakness, fractures and CVD • Evidence of reduction in disease progression • Evidence of improved nutrition

  14. Fluid overload and CKD • Always difficult • Symptom control versus kidney function? • Poor long term prognosis • What about other drugs towards end of life?

  15. Mr D • 82 year old gentleman: short of breath for 2 weeks, gradually increasing, high INR • Background: ICM with biventricular PPM, IHD – PCI to LAD, AF, stage 3B CKD (baseline eGFR 32), gout, BPH, diabetes • Medications: Aspirin 75mg od, Clopidogrel 75mg od, Warfarin, Allopurinol 100mg od, Lisinopril 5mg od, Digoxin 250mcg od, Finasteride 5mg od, Atorvastatin 40mg od, Furosemide 40mg bd, Gliclazide 40mg bd, codydramol2 QDS • Recent acute gout: treated with 5/7 Naproxen 500mg bd • On admission: heart rate 118/min, BP 93/63, fluid overloaded, drowsy • Bloods: Hb 112, Na 132, K 5.7, creatinine 287 (eGFR 19), ALT 488, ALP 316, CRP 20, INR 13.5, Glucose 4.5

  16. Management plan • Stop ACEI- more effect on kidney function than diuretics • Stop warfarin, aspirin and clopidogrel • Check digoxin level- stop digoxin • Stop codeine based analgesia • Stop gliclazide • High dose IV frusemide- started at 80mg IV am and lunchtime • Daily weights- much easier than input-output charts! Fluid restrict • SBP consistently 90-100mmHg • Continued deterioration in renal function: Cr 287 – 352 in 2 days- diuretic dose increased to 120mg am, 80mg lunchtime • Slowly started to lose weight • Renal function started to improve and back to near normal by day 7 • Symptomatically much improved

  17. Points to remember • High dose diuretic better for symptom control than ACEI • Renal function and blood pressure may improve if off loaded • Diabetes drugs especially sulphonylureas need reviewing- prolonged hypoglycaemia • How long to fluid restrict? • Consider using palliative care medications and referral early rather than late • Which opiate is best in CKD?

  18. What message to take home in later stages CKD- the geriatricians opinion! • Don’t make renal function and disease progression your main goal • All the skills of the geriatrician are required to get it right • New ways to diagnose and classify CKD- but these won’t affect acute care • Advised you on current management of some of the acute presentations- fractures, anaemia, CCF • Await answers to trials on treatment of acidosis • Work together with the primary care team, renal team and palliative team to provide best care for your patient

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