Chronic renal disease in the elderly - Nephrologisches Seminar · 2018. 11. 1. · •During the...

Chronic renal disease intheelderly:

areallpigs tobe considered equal?

W.VanBiesen,GhentUniversityHospital

Elwood etal,cJASN,2013

Elderly andCKD:athematicsynthesis

Overview• CKDintheelderly:adisease?

– How toassess renal function intheelderly?– How toassess progression intheelderly?– How toassess riskofdeath intheelderly?

• How toassess functional statusintheelderly?• How toassess nutritional statusintheelderly?• Todialyseor not todialyse?Isthat thequestion?

• Some ethical considerations

Probability ambiguity

complexity

CONTEXT

Rembrandt: Portrait of an Old Man in Red Thanks toRembrandandEdwina Brown

Sorrowing Old Man (‘At Eternity’s Gates’) by van GoghThanks toVanGoghandEdwina Brown

IsCKDadisease intheelderly?

IsCKDadisease intheelderly?

Estimating renal function intheelderly

AJKD,2012

AJKD,2012

AJKD,2012

AJKD,2012

Q1:Whatparametershouldbeusedinolder(frail??)patientstoestimatekidneyfunctionfordose

adaptationpurpose?

1.1Werecommend using estimation equations correcting for differences increatinine generation rather than plain serumcreatinine toassess renal function inolder patients (1A)1.2Werecommend there isinsufficient evidence toprefer one estimationequationoveranother asallestimation equations performequally poor andsubstantialmisclassification can occur with allequations inolder patientswith deviatingbodycomposition (1B).1.3Werecommend toactuallymeasure renal function if accurateandpreciseestimation ofGFRisneeded.

DrugDose Adaptation

BMCgeriatrics,2013

Q1:Whatparametershouldbeusedinolderpatientstoestimatekidneyfunctionfordoseadaptationpurpose?

• Advice for clinical practice:• kidney function can vary overtimeandshould be followed repetitively usingthesame equation• estimationequations can not be used inpatientswith acutechanges intheirkidney function• evenwhen usingestablished formulae inthis specific population, differentformulas can result indifferentclassifications• serumlevels ofdrugsdepend upon absoluterather thanbodysize correctedclearance• Allformula other than Cockcroft andGault require additional correction forBSAtoobtain absolutevalues• Fordrugswith anarrowtoxic/therapeutic range,regularmeasurement ofserumconcentrations can provideuseful information.However,differences inprotein bindingbetween uraemicvs nonuraemicpatients occur,which mightnecessitate theuse ofdifferenttargetlevels oftotal drugconcentration.

Riskofdeath vs riskofESRDinfunction ofage

O’Hare,JASN,2007

Riskfor ESRDinfunction ofbaselineeGFR

Gramsetal,AJKD2015

Q2:Whatisthemostreliablescoretopredictprogresion ofchronickidneydiseaseinolderpatientswithCKDstage3borhigher

2.1Werecommend theKidney Failure RiskEquation (KFRE)predicts sufficiently well theriskfor progression ofchronic kidney disease inolder patients with CKDstage3bor higher (1B)

Non-Frail elderly

Frailty inpatients on haemodialysis inUS

0

10

20

30

40

50

60

Frailty%

MacAdams-deMarco,JAmSocGeriatry,2013

Frailty inpatients on haemodialysis inUS

0

10

20

30

40

50

60

Frailty%

Noage effect

MacAdams-deMarco,JAmSocGeriatry,2013

Whatisfrailty?

• Decreasedphysiologicreservesordysregulationofmultiplephysiologicsystems– associatedwithageand/orchronicillness

• Presentsascompositeofpoorphysicalfunction,exhaustion,lowphysicalactivityandweightloss

• Associatedwithhigherriskoffalls,cognitiveimpairment,hospitalizationanddeath

• MorecommoninCKDthangeneralpopulation

Commonclinicalpresentationsoffrailty

• Non-specific:extremefatigue,unexplainedweightlossandfrequentinfections

• Falls:balanceandgaitimpairmentimportantriskfactorsandaremajorfeaturesoffrailty

• Delirium:rapidonsetoffluctuatingconfusionwhenadmittedtohospital.Associatedwithadverseoutcomes

• Fluctuatingdisability:daytodayinstabilityresultingingoodandbaddays

Rockwood etal,CMAJ2005

Rockwood etal,CMAJ2005

Q3:Whatisthethe mostreliablemodeltopredictmortalityinolderpatientswithCKDstage3borhigher

3.1Werecommend theBansal scorepredictssufficiently well theriskfor mortality inolderpatients with CKDstage3bor higher not on dialysis

3.2Werecommend that inpatient atlowriskintheBansal score,ascoreincluding assessment offrailtyshould be performed

Tostartor not tostartdialysisisthat thequestion?

• Dataset2001-2003• Baselineinformationatdialysisinitiationincluded

• age,gender,• eGFR basedoncreatinine andtheMDRDformula• bodymassindex(BMI)• serumalbuminthemonthprecedingdialysisstart• diabetes(type1or2)• congestiveheartfailure(NewYorkHeartAssociationstagesItoIV),ischaemic heartdisease(includinghistoryofmyocardialinfarction,coronaryvasculardisease,coronaryarterybypasssurgery,angioplastyorabnormalangiography)• peripheralvasculardisease(Leriche classificationstagesItoIV)• cerebrovascular disease• arrhythmia• chronicobstructivepulmonarydisease(COPD)• malignancy,livercirrhosis,• mentaldisorders(definedtoincludedementiaandpsychosis)• initialdialysismodality• latereferral(definedasstartingdialysislessthan3monthsafterfirstcontactwiththenephrologydepartment. Peetersetal,BMCnephrology,2016

• Duringtheobservationperiod,3472patientsstartedrenalreplacementtherapy.

• For793patients(22.8%)informationononeparameteroftheREINscorewasmissing,makingaREIN scorecalculationimpossible,leaving2679patientsavailableforanalysis.Therewasnodifferencebetweenthosewithversuswithoutmissingdata.

• Morethanhalf(56.4%)andalmostthreequarters(70.3%)ofthoseolderthan85and90yearsofagerespectivelyatstartofdialysishadanaREIN stageof3or4.

• Weregistered276(8.6%),453(14.1%)and681(19.6%)deathsat3,6and12monthsrespectively.• Patientswhodiedduringthefirst3monthswere

•older(74.3±9.9vs 67.0±14.5years,p<0.001),• hadahigheraREIN scoreatstart(6.4±2.7vs 3.9±2.7,p<0.001)• alowerserumcreatinine (6.1±3.8vs 6.7±3.1mg/dl,p<0.01)• alowerbodyweight(69.4±15.5 vs 71.7±15.7kg,p=0.03)

Peetersetal,BMCnephrology,2016

RiskfactorsPoints

GenderMale 1

Female 0Age(years)

[75-80[ 0[80-85[ 0[85-90[ 2>=90 3

Congestiveheart failureNo 0

StageI-II 2StageIII-IV 4

PeripheralvasculardiseaseNoor stageI-II 0

StageIII-IV 1Arrhythmia

No 0Yes 1

CancerNo 0Yes 2

SeverebehaviouraldisorderNo 0Yes 2

SerumAlbumin (g/l)<25 5

[25-30[ 3[30-35[ 2

≥35 0

0

10

20

30

40

50

60

3month 6month 12month

≤4

5or6

7or8

≥9

Peetersetal,BMCnephrology,2016Peetersetal,BMCnephrology,2016

riskstratification for survivalaREINscore N

≤4 1381 1236 1102 979 865 805 720 454 2295-6 458 367 287 235 183 158 134 81 407-8 222 166 127 105 78 61 50 24 14≥9 92 66 49 35 27 19 14 7 5

Peetersetal,BMCnephrology,2016

3month survivalriskstratification

Peetersetal,BMCnephrology,2016

12month survivalriskstratification

Peetersetal,BMCnephrology,2016

Q3:Whatisthethe mostreliablemodeltopredictmortalityinolderpatientswithCKDstage3borhigher

3.1Werecommend theBansal scorepredictssufficiently well theriskfor mortality inolderpatients with CKDstage3bor higher not on dialysis

3.2Werecommend that inpatient atlowriskintheBansal score,ascoreincluding assessment offrailtyshould be performed

3.3Werecommend theREINscorepredictssufficiently well theriskfor mortality inpatientsstarting renal replacement therapies

Asystematic review on conservative care

RoleofsupportivecareinadvancedCKDmanagement

Aggressivetreatment Bereave-ment

Supportivecare

Time

DialysisTransplantAccessSurgeryAntibiotics

PaincontrolSymptomcontrolPsycho-socialsupportAwarenessofpatientgoalsandconcerns

Withdrawalofdialysis:EuropeanNephrologistsperceptions

Percentageofpatients withdrawn fromdialysis overthelast12months

Polltheaudience

58,6

36,4

4,10,9

<1% 1-5%6-10% >10%

Percentageofpatients withdrawn fromdialysis overthelast12months

YES

NO

0

10

20

30

40

50

60

70

80

Permitdeathlaw

ExplicitPalliativeCarelaw

56,2%

24,2%

43,8%

75,8%

Physician perception oflegal backgroundofdialysis withdrawal

Physician perception oflegal backgroundofdialysis withdrawal

PanelB

Physician perception oflegal backgroundofdialysis withdrawal

0 10 20 30 40 50 60 70 80

relieveburdenoffamilylackofsuitabletransport

lifeexpectancydoesnotoutweighsufferingotherreasons

Ibelievethatpatientswhoactuallywithdrewdidthisbecause

0 5 10 15 20 25 30 35 40

dontknowlackofcommitmentnephrologist

lackofknowledgeofnephrologist onPClackofsuitablefacilitiesforPClackofsocialsupportathome

afraidofstopmedicalsupervision

Ibelievethatpatientswhoconsideredwithdrawalbutcontinueddialysis

Polltheaudience

Polltheaudience

0 10 20 30 40 50 60 70 80

relieveburdenoffamilylackofsuitabletransport

lifeexpectancydoesnotoutweighsufferingotherreasons

Ibelievethatpatientswhoactuallywithdrewdidthisbecause

0 5 10 15 20 25 30 35 40

dontknowlackofcommitmentnephrologist

lackofknowledgeofnephrologist onPClackofsuitablefacilitiesforPClackofsocialsupportathome

afraidofstopmedicalsupervision

Ibelievethatpatientswhoconsideredwithdrawalbutcontinueddialysis

0 5 10 15 20 25 30 35 40 45

don'tknow

morePCspecialistswereavailable

nephrologists hadmoreexpertiseinPC

betterlogisticalserviceswereavailable

Ibelievemorepatientswouldoptforwithdrawalif

Polltheaudience

0 5 10 15 20 25 30 35 40 45

don'tknow

morePCspecialistswereavailable

nephrologists hadmoreexpertiseinPC

betterlogisticalserviceswereavailable

Ibelievemorepatientswouldoptforwithdrawalif

CaringvsCuring

Caring:compassion,respectandconcernfortheother

vsCuring:biomedicalintervention

Question1• A85year old women with longstandingdiabetesand

amputations,dialysis dependence,bilateral diabetic retinopathy,ishospitalised because ofdiarrhea.

• AlastChest Xray before dismissionshowsan enlarged hilus,suspicious for amalignancy.What doyou do?– A:you planaCTthoraxandabronchoscopy toestablish thediagnosis

morecertain.– B:you planaCTthorax,aPETscan,abone scintigraphy anda

bronchoscopy for acompletestaging.– C:you just dismissthepatient asplanned– D:You ask theopinion ofthepatient anddiscuss theoption ofwithdrawal

ofdialysis if things goworse– E:You ask theopinion ofthefamily,but donot speak with thepatient

Question 2• Your85yearoldgrandmotherwithlongstandingdiabetesand

amputations,dialysisdependence,bilateraldiabeticretinopathy,ishospitalisedbecauseofdiarrhea.

• AlastChestXraybeforedismissionshowsanenlargedhilus,suspiciousforamalignancy.Whatdoyoudo?– A:youplanaCTthoraxandabronchoscopytoestablishthediagnosis

morecertain.– B:youplanaCTthorax,aPETscan,abonescintigraphyanda

bronchoscopyforacompletestaging.– C:youjustdismissthepatientasplanned– D:Youasktheopinionofthepatientanddiscusstheoptionofwithdrawal

ofdialysisifthingsgoworse– E:Youasktheopinionofthefamily,butdonotspeakwiththepatient

Question3• Yousufferfromanincurabledisease.Whomwouldyouprefertohaveonyourbedside

Question3• Yousufferfromanincurabledisease.Whomwouldyouprefertohaveonyourbedside– A:theworldauthorityforthatdisease

Question3• Yousufferfromanincurabledisease.Whomwouldyouprefertohaveonyourbedside– A:theworldauthorityforthatdisease– B:yourbestfriend

Question3• You suffer from an incurable disease.Whomwould you prefer tohaveon your bedside– A:theworld authority for that disease– B:your bestfriend– C:aphysician who takes careofyour symptoms,andlistens toyou

RRTatICU:acostutilityanalysis

Laukkanenetal,IntensiveCareMedicine,2012

Wheredowewanttogo...• Limit(restrict)accesstocure

•

Wheredowewanttogo...• Limit(restrict)accesstocure

• onwhichgrounds?• comorbidity

•

Wheredowewanttogo...• Limit(restrict)accesstocure

• onwhichgrounds?• comorbidity,

•

Wheredowewanttogo...• Limit(restrict)accesstocure

• onwhichgrounds?• comorbidity,age,

•

Wheredowewanttogo...• Limit(restrict)accesstocure

• onwhichgrounds?• comorbidity,age,diabetes,...color...

•

Wheredowewanttogo...• Limit(restrict)accesstocure

• onwhichgrounds?• comorbidity,age,diabetes,...color...sexualorientation...

•

Wheredowewanttogo...• Limit(restrict)accesstocure

• onwhichgrounds?• comorbidity,age,diabetes,...color...sexualorientation...

•

Thesis

Weinvesttoomuchmedical-technical(CURE)attentiontoveryfrail

patientsattheexpenseoftheCAREforthem

àndattheexpenseofthesewhowouldREALYbenefit.

Probability ambiguity

complexity

DialysetoliveNot

Livetodialyse

Mindfullpractice:

Tocuresometimes,torelieveoften,tocarealways