Elderly people with CKD 4 5 - ANZDATA · 2019-02-15 · 1 82-86 87-91 92-96 97-01 45-54 yr65+ yr 65+ yr Stewart, McCredie, McDonald, Nephrology, 2004. Late referralLate referral 80

“Elderly” people with CKD 4/5Elderly people with CKD 4/5

Stephen McDonaldTQEH Renal UnitTQEH Renal Unit

ANZDATA Registry

What is elderly?What is elderly?

• For today’s purposes, arbitrarily 65+

www.anzdata.org.au

Possible transitionsPossible transitions

CKD 4 CKD 5CKD 4 CKD 5

RRTNon-renal death Death due to

kidney failure

DeathH d di t h

$64 question

How do we predict who goes which way?

What happens to CKD 4?What happens to CKD 4?

• 2 key outcomes– Death

• From non-renal causes• From end-stage kidney diseaseFrom end stage kidney disease

– Renal replacement therapy

www.anzdata.org.au

What do we know?What do we know?

• Good information about prevalence and outcomes of treated RRT among elderlyg ypeople

• Reasonable information about outcomes• Reasonable information about outcomes in CKD 4/5 from international studies– ?extrapolation to Australia

• Some information about prevalence ofSome information about prevalence of CKD 4/5 in “free-living” Australian population (AusDiab Blue Mountains)

www.anzdata.org.au

population (AusDiab, Blue Mountains)

Extremes of ageExtremes of age100

90

ars)

80

Age

(yea

70

60

1970 1980 1990 2000 2010Year

www.anzdata.org.auAge of oldest RRT start, Australia

Age of dialysis patientsAge of dialysis patientsRest Australia QEH

0- 25-45- 65-75- 85-

Graphs by qehPrevalent dialysis modality, Australia 2007

Prevalent dialysis patientsPrevalent dialysis patientsRest Australia QEH

8,000

10,000

200

250

4,000

6,000

100

150

Num

ber

0

2,000

,

0

50

N

0 0199019911992199319941995199619971998199920002001200220032004200520062007

199019911992199319941995199619971998199920002001200220032004200520062007

0- 25-0- 25-45- 65-75- 85-

Graphs by qeh

www.anzdata.org.au

Graphs by qehPrevalent dialysis modality, Australia 2007

Prevalent dialysis modalityPrevalent dialysis modalityQ

10.05%3.619% 13 08%

Rest Australia QEH

11.26%

13.08%

10%

27.92%

47.16%

18.46%58.46%

APD CAPDHospital HD Satellite HDHome HD

www.anzdata.org.auAged >=65 at end 2007Prevalent dialysis modality, Australia 2007

Number of new RRTNumber of new RRT3000

2500

3000

85+

2000

per y

ear 75-84

65-7455-64

1000

1500

Num

ber p

55 6445-5435-4425 34

500

N 25-3415-245-14

0

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

0-4

www.anzdata.org.au

Population change?Population change?

20000000

15000000

ulat

ion

5000000

10000000

Pop

0 198919901991199219931994199519961997199819992000200120022003200420052006200720089 0 2 3 4 5 6 7 8 9 0 2 3 4 5 6 7 8

0 1525 3545 55

www.anzdata.org.auA65 75

Australian population, ABS 32010.9 2008

Incidence of RRT in Australia

0-24 25-44 45-64

AustraliaIncident RRT by age

15

20

60

70

160

180

0 24 25 44 45 64

5

10

40

50

120

140

1995 2000 2005 2010

n pe

r yea

r

400

500

300

400

65-74 75+

per m

illion

200

300

100

200

1995 2000 2005 2010 1995 2000 2005 2010

Yeartreated ESKD only

Primary renal diseasePrimary renal disease

80

100

40

60

Perc

ent

20

40

045-64 65-74 75-84 85+

Primary renal diseaseGlomerulonephritis AnalgaesicHypertension / vascular CysticReflux nephropathy Diabetic nephropathy

Primary renal disease

www.anzdata.org.auRRT starts, Australia, 2003-7

Miscellaneous Uncertain cause

What is driving the increase in rate?What is driving the increase in rate?

Type 2 Diabetic Nephropathy

100

Polycystic kidney disease

100

mill

ion

mill

ion

10

Rat

e pe

r m 10

Rat

e pe

r m

182-86 87-91 92-96 97-01

182-86 87-91 92-96 97-01

45-54 yr 65+ yr 45-54 yr 65+ yr

Stewart, McCredie, McDonald, Nephrology, 2004

Late referralLate referral

80

100

60

80

rcen

t

40

Per

0

20

45 64 65 74 75 84 8545-64 65-74 75-84 85+

No YesLate referral

www.anzdata.org.au

RRT starts, Australia, 2003-7

Untreated ESKDUntreated ESKD

• We don’t know number of deaths from untreated ESKD

• Death certificate data unreliable (Li et al 2001 ANZJPH)

20% f d th tifi t f l d i– 20% of death certificates of people dying during RRT made no mention of renal disease

i i l i t d dias principal or associated disease• 66% dialysis patients• 38% circulatory deaths, 16% endocrine and

nutritional, 15% neoplasms

www.anzdata.org.au

Outcomes in CKD4/5Outcomes in CKD4/5

• Australian data from AusDiab– Some selection bias– Only current national population-based data

Prevalence of CKD– Prevalence of CKD• For 65-74 y.o., 24% stage3, 0.8% CKD 4/5

F 75 38% CKD3 2 5% CKD4/5• For 75+ y.o. 38% CKD3, 2.5% CKD4/5

www.anzdata.org.au

Crude Mortality Rates: Age ≥65 Years

AusDiab data. (K Polkinghorne)

CKD Stage & All Cause Mortality: Adjusted HR


International experienceInternational experience

• Population based cohort based on KaiserPermanente Northwest division– 42293 people eGFR 15-90 ml/min/1.93m2

– Included 777 people CKD4• Mean age 73.6 + 13.6• Followed for mean 37.6 months

O• Outcomes– 44.6% died, 2.3% transplanted, 17.6% started dialysis– 27% no events, (7% disenrolled)

Keith et al Ann int Med 2004

International elderly cohort 2International elderly cohort 2

• 2 area health boards– Southern Health Board in Northern Ireland and the

Lothian and Borders Health Boards in South-EastScotland 1/1/98 31/12/02 1 21 illi l ti– 1/1/98 – 31/12/02, 1.21 million population

– Caucasian (>98%)• 396 CKD 4 patients referred, followed for 3.76

years, – Median age 71, 1/3 over 75 years

• 180/396 (45.4%) died, 89 (22.5%) treated with Conway et al, NDT 2009 24:1930

( ) ( )RRT, 10 (2.5%) lost to followup

Elderly cohortElderly cohortRisk of death Risk of RRT

4 4

2H

R

2H

R

51

H

.51

H

.25

.5

e e e a A A e e

.25

e e e a A A e eeGFR

>=25

eGFR

20-24

eGFR

<20

age <65

Age 65-74

Age 75+

eGFR

decline

eGFR

decline

eGFR

>=25

eGFR

20-24

eGFR

<20

age <65

Age 65-74

Age 75+

eGFR

decline

eGFR

decline <4 >4 <4 >4

created from Conway NDT 2009

Other cohortsOther cohorts

Figure 5 (A) Kaplan-Meier curves for renal replacement therapy (RRT) by estimated glomerular filtration rate (eGFR). Using eGFR categories, significant differences in risk of RRT by eGFR levels are shown. (B) Kaplan-Meier curves for death before RRT by eGFR level. Using the same categories, significant differences in risk of death by eGFR levels are shown; most notably, the curves separate at 18 months. Levin et al AJKD 2008

BC Provincial CKD Registry – eGFR<30, mean age 66 years

Modality of elderly startersModality of elderly starters100

80

60

erce

nt

40

Pe

20

0<45 45-64 65-74 75-84 85+

G f90 day modality

www.anzdata.org.auNew RRT Australia 2003-7 by age at start

HD PD Graft

Survival on dialysisSurvival on dialysisKaplan-Meier survival estimates

0 75

1.00

0.50

0.75

0.25

0.00

0 2 4 6 8 100 2 4 6 8 10Years

65 74 75 84 85+Age at RRT start

65-74 75-84 85+

Survival, all new RRT 1995-2007, Australia only

Survival on dialysisSurvival on dialysis

Age category 25th centile 50th centile 75th centile65-74 19.7 42.7 78.275-84 14.0 31.1 56.085+ 8.8 20.2 36.3

Survival by age at first dialysis (months)

A Lif t Lif tAge Life expectancy (male)

Life expectancy (female)

70 14.7 17.480 8.3 10.085 6.0 7.1

www.anzdata.org.au Life expectancy (years), ABS cat 3302055001

Effect of comorbiditiesEffect of comorbiditiesF t Ti tiFactor Time ratioDiabetes 0.90 [0.85-0.95]Coronary artery disease 0 78 [0 74-0 83]Coronary artery disease 0.78 [0.74 0.83]Cerebrovascular disease 0.83 [0.78 to 0.88]Peripheral vasc disease 0.78 [0.73 to 0.82]Chronic lung disease 0.79 [0.74 to 0.84]Age 75-84 0.69 [0.66 to 0.73]Age 85+ 0.48 [0.41 to 0.56]Male gender 1.15 [1.10 to 1.21]

Time ratios from multivariate analysis (assuming exponential distribution).

www.anzdata.org.auRatios are MULTIPLICATIVE.

Outcomes by comorbidityOutcomes by comorbidity

1065-74 75-84 85+

5

Yea

rs

0

0 1 2 3+ 0 1 2 3+ 0 1 2 3+Comorbids

25th& 75th centiles 50th centile

Survival, Australian new RRT 1995-2007

Does modality matter?Does modality matter?402 40

(%)

1.5

2

30

on o

f coh

ort

.75

1

azar

d ra

tio

20

Pro

porti

o

.5

Ha

10

No comorbid, <60No comorbid, >=60 Comorbid, <60 Comorbid, >=60Comorbidity & agey g

PD vs HD in first 12 monthsPD vs HD after 12 months

Figure 4 Risk of PD compared with HD stratified by age and the presence of any comorbidity

McDonald, S. P. et al. J Am Soc Nephrol 2009;20:155-163

Figure 4. Risk of PD compared with HD stratified by age and the presence of any comorbidity

Does dialysis prolong survival?Does dialysis prolong survival?

• Not amenable to RCT• Data from cohort of patients 75+ yearsData from cohort of patients 75+ years

receiving care in multidisciplinary clinic in 4 hospitals in South Thames4 hospitals in South Thames– 52 in dialysis pathway

• 8 died , 16 not started by end of study– 79 conservative

• 51 died, 0 conversions to dialysis pathway

Murtagh et al, NDT 2007


Fig. 2. Kaplan–Meier survival curves comparing the dialysis and conservative groups (log rank statistic = 13.63, P < 0.001).

Survival of Murtagh cohort – from time of eGFR=15. Murtagh, NDT, 2007

( g , )


Fig. 3. Kaplan–Meier survival curves for those with high comorbidity (score = 2), comparing dialysis and conservative groups (log rank statistic <0 001 df 1 P = 0 98)

Survival of Murtagh cohort – from time of eGFR=15. Murtagh, NDT, 2007

comparing dialysis and conservative groups (log rank statistic <0.001, df 1, P = 0.98).

ConclusionsConclusions

• Numbers of older people starting dialysis are increasingg– Increasing disease burden

Increasing propensity to treat– Increasing propensity to treat• Only a small proportion of people with

CKD4/5 will proceed to RRT• Outcomes are dependent onOutcomes are dependent on

– Agebidit– comorbidity

Best care for CKD4/5 in the ideal world

• Accurately identify who will reach “ESKD” • Among that group identify who in thatAmong that group identify who in that

group will benefit from dialysisS l di i t th t j d t– Several dimensions to that judgement

• Quantity of life• Quality of life

www.anzdata.org.au

What don’t we knowWhat don t we know

• Ongoing information about outcomes in Australia among people with CKD 4/5g p p– Is prevalence stable?

Disease progression?– Disease progression?– Various ethnic and demographic groups

• Survival

www.anzdata.org.au

Today’s talkToday s talk

• What is known about the number and rate of “elderly” people In Australia y p p

• What the outcomes are when treated with renal replacement therapyrenal replacement therapy

www.anzdata.org.au

Crude Mortality Rates: Age <65 Years


Elderly cohort 3Elderly cohort 3

Southhampton UK trial of 15336 people 75+ years old GP based multidimensionalSouthhampton UK trial of 15336 people 75+ years old, GP based multidimensional health care. 7.25 years followup; 1.7% eGFR <30; 9.7% eGFR 30-44; 32% eGFR45-59. Roderick et al, AJKD 2009

CKD Stage & All Cause Mortality: Unadjusted HRUnadjusted HR

CKD Stage & All MortalityCKD Stage & All Mortality


Documents

Elderly people with CKD 4 5 - ANZDATA · 2019-02-15 · 1 82-86 87-91 92-96 97-01 45-54 yr65+ yr 65+ yr Stewart, McCredie, McDonald, Nephrology, 2004. Late referralLate referral 80