Approach to Advanced Kidney Disease Management in the Elderly

1. Approach to Advanced Kidney Disease Management in the Elderly Source: Schell JO, Germain MJ, Finkelstein FO, et al. An integrative approach to advanced kidney disease in the elderly. Adv Chronic Kidney Dis. 2010;17(4):368–377.

2. Introduction • Mrs. DB, an 82-year-old woman with long-standing hypertension and poorly controlled diabetes had recent weight loss. • Besides this her recent problem included worsening renal function with accelerated declines in her glomerular filtration rate (GFR) (12 mL/min). • For her worsening renal function, she was referred to a nephrologist. • She complained of poor appetite and disinterest in community activities, which according to her was due to aging. • On examination, she appeared and had mild lower extremity swelling. • Laboratory examination was suggestive of advanced renal failure, with low albumin and hemoglobin. • These kinds of patients are often referred to nephrologists. • Chronic kidney disease (CKD) is progressively increasing due to the increase in the geriatric age group. • Several studies have shown that an elderly patient with CKD are more likely to have comorbidities, walking impairments and decrements in the quality of life as compared to the elderly with normal renal function. • A major dilemma for the nephrologist treating the elderly patient, such as Mrs. DB, is to decide whether to initiate dialysis or treat conservatively. • In addition, the nephrologist has to decide how best to attend to the patient’s burden of disease and suffering.

3. Dialysis or Conservative Management • Elderly patients like Mrs. DB represent the fastest growing segment of the dialysis population. • A study in the US has shown that the rate of elderly patients (>75 years) initiating dialysis is about 2000 per million population, an increase of about 11% since the year 2000. • The median age of patients starting dialysis has also increased from 56 years in 1986 to 64.4 years in 2008. • Although the rates of dialysis initiation continue to rise, in the elderly patients the survival has not markedly increased and there are often deficits in the quality of life. • Recent studies have shown that in elderly patients the initiation of dialysis was associated with poor survival (see Fig. 1), with a rapid decline in the functional status before death (see Fig. 2). • Recent research indicates that elderly patients with advanced kidney disease have a high mortality regardless of the treatment approach (conservative treatment or dialysis). • The annual mortality rate of patients undergoing dialysis is approximately 23% in USA and, with only about 38% surviving 5 years. • The mortality rate in elderly dialysis patients (􀁴65 years) is six times higher than those in the general population.

4. Elderly patients with advanced kidney disease often have comorbidities, such as diabetes, congestive heart failure and coronary artery disease. • In addition, most patients have poor physical functioning including disability in ambulation. • In a study, dialysis initiation was associated with a functional decline in dialysis patients that was observed to be independent of age, gender, race and functional status before initiation of dialysis. • The results showed that after 12 months of dialysis 58% of patients in the cohort had died and only 13% maintained predialysis functional status.

5. Several studies have shown that outcomes after hospitalization and invasive procedures are poor in patients with CKD. • These patients are at a significant risk of sudden cardiac death and decreased survival at 6 months after hospitalization following cardiopulmonary resuscitation as compared to controls. • This evidence shows that elderly patients with advanced kidney disease, often have several associated comorbidities. • This significantly increases the risk for invasive procedures, which often negatively affects their survival and quality of life. • Hence before aggressive management is considered, the patient should be thoroughly evaluated and detailed information should be given to the patient regarding disease progression and management.

6. Health-Related Quality of Life in the Elderly • Elderly patients with kidney disease often have compromised health-related quality of life (HRQOL) in a variety of HRQOL domains (physical, mental or emotional). • The impairments are more pronounced for physical aspects as compared to mental or emotional domains. • It has been noted that reductions in HRQOL scores are associated with decreased survival and increased risk of increased hospitalization. • Impairments of physical aspects of HRQOL are more marked in elderly patients as compared to younger patients. • Depression has also been observed to be prevalent in end-stage renal disease (ESRD) and dialysis patients, and has been observed to worsen outcomes. • In a prospective study, the authors followed hemodialysis (HD) patients (n=98) on the basis of direct patient interviews and reported that about 25% of the patients had clinical depression. • Of these patients, about 80% had died or were hospitalized at the time of follow-up, as compared to 43.1% of the nondepressed patients. Several other studies have also shown similar results.

7. This suggests the existence of a strong relationship between depression and mortality. • As depression is potentially treatable these facts should be considered significant. • Hence, besides, focusing on ‘life-sustaining’ therapy such as dialysis, a major concern while treating should be measures to improve the HRQOL and decrease the burden of disease and therapy.

8. Prognostication of Kidney Disease:A Challenge • Deciding the management approach in patients with advanced kidney disease can be a major challenge for the nephrologists. • In high-risk patients, it can be very difficult to decide whether the benefits of dialysis initiation outweigh the risks, and even in the patients already on dialysis, it is important to identify chronically debilitated patients with a poor QOL who would benefit from withdrawal from dialysis and only palliative care. • Hence, it is important that a patient is evaluated properly before initiation of dialysis and the prognosis, the risk associated with treatment and mortality are explained to the patient. • This should be a norm rather than exception as patients and the care providers desire to know information about prognosis and survival.

9. Initiation Practices for Dialysis • Mrs. DB’s presentation with advanced kidney disease is a common scenario for the nephrologist and most of these patients are often started on dialysis without adequate predialysis visits and evaluation. • In most patients, dialysis is often initiated using HD venous catheters instead of permanent access, such as a native fistula. • In a study, HD patients >67 years of age with venous catheters have a mortality rate of 41.5% as compared to 24.9% in patients with native fistula. • In several studies, these factors have been implicated as predictors of early mortality. • Lack of adequate referral is also a factor that limits adequate management of patients with renal disease.

10. In a study, 60.3% elderly patients ≥75 years were considered as late referral as compared to 42.9% of nonelderly patients. • This limits the opportunity for a nephrologist to evaluate the patients adequately and to build and maintain trust. • The mortality of elderly patients who are not adequately evaluated is high, mostly due to infectious complications and hospitalizations. • A retrospective analysis of hospitalized patients who were started on dialysis, showed that the mean survival was 19 months, 29.4 months and 52 months for patients aged >75 years, 65–74 years, and 50–65 years, respectively. • Besides age-associated comorbid conditions and functional limitation were also important in predicting survival and mortality.

11. Studies have shown that timely referral and planned dialysis initiation can significantly improve the quality of life and survival of these patients. • Timely evaluation by the nephrologist needs improved referral guidelines for primary care physicians and good communication between nephrologists and referring physicians.

12. Integrated Management of Patients with Kidney Disease • According to studies, many patients with advanced CKD are more likely to die early after starting dialysis than with conservative management. • The progression of kidney disease may be slower with conservative management. • This suggests that many elderly patients may survive with low GFRs and do not need dialysis. • In these patients, starting dialysis may result in the rapid decline of residual renal • function and worsen the prognosis. • Hence, an approach to maintain the residual renal function and the symptomatic treatment may be reasonable in elderly patients with advanced CKD. • If patients, such as Mrs. DB, are referred timely and are appropriately evaluated for risks and decrements in their quality of life before dialysis initiation, more patients will be started on other treatment plans including conservative management, which will probably improve the overall prognosis of these patients.

13. Conclusion • Patients like Mrs. DB are not unique and therefore the highrisk elderly patients with advanced kidney disease should be evaluated optimally before dialysis is initiated. • As a doctor, the treatment approach should be patient-centered rather than the disease alone.

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