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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