chronic renal disease in the elderly - nephrologisches seminar · 2018. 11. 1. · •during the...
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Chronic renal disease intheelderly:
areallpigs tobe considered equal?
W.VanBiesen,GhentUniversityHospital
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Elwood etal,cJASN,2013
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Elderly andCKD:athematicsynthesis
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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
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Probability ambiguity
complexity
CONTEXT
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Rembrandt: Portrait of an Old Man in Red Thanks toRembrandandEdwina Brown
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Sorrowing Old Man (‘At Eternity’s Gates’) by van GoghThanks toVanGoghandEdwina Brown
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IsCKDadisease intheelderly?
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IsCKDadisease intheelderly?
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Estimating renal function intheelderly
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AJKD,2012
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AJKD,2012
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AJKD,2012
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AJKD,2012
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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.
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DrugDose Adaptation
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BMCgeriatrics,2013
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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.
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Riskofdeath vs riskofESRDinfunction ofage
O’Hare,JASN,2007
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Riskfor ESRDinfunction ofbaselineeGFR
Gramsetal,AJKD2015
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Q2:Whatisthemostreliablescoretopredictprogresion ofchronickidneydiseaseinolderpatientswithCKDstage3borhigher
2.1Werecommend theKidney Failure RiskEquation (KFRE)predicts sufficiently well theriskfor progression ofchronic kidney disease inolder patients with CKDstage3bor higher (1B)
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Non-Frail elderly
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Frailty inpatients on haemodialysis inUS
0
10
20
30
40
50
60
Frailty%
MacAdams-deMarco,JAmSocGeriatry,2013
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Frailty inpatients on haemodialysis inUS
0
10
20
30
40
50
60
Frailty%
Noage effect
MacAdams-deMarco,JAmSocGeriatry,2013
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Whatisfrailty?
• Decreasedphysiologicreservesordysregulationofmultiplephysiologicsystems– associatedwithageand/orchronicillness
• Presentsascompositeofpoorphysicalfunction,exhaustion,lowphysicalactivityandweightloss
• Associatedwithhigherriskoffalls,cognitiveimpairment,hospitalizationanddeath
• MorecommoninCKDthangeneralpopulation
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Commonclinicalpresentationsoffrailty
• Non-specific:extremefatigue,unexplainedweightlossandfrequentinfections
• Falls:balanceandgaitimpairmentimportantriskfactorsandaremajorfeaturesoffrailty
• Delirium:rapidonsetoffluctuatingconfusionwhenadmittedtohospital.Associatedwithadverseoutcomes
• Fluctuatingdisability:daytodayinstabilityresultingingoodandbaddays
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Rockwood etal,CMAJ2005
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Rockwood etal,CMAJ2005
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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
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Tostartor not tostartdialysisisthat thequestion?
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• 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
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• 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
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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
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0
10
20
30
40
50
60
3month 6month 12month
≤4
5or6
7or8
≥9
Peetersetal,BMCnephrology,2016Peetersetal,BMCnephrology,2016
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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
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3month survivalriskstratification
Peetersetal,BMCnephrology,2016
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12month survivalriskstratification
Peetersetal,BMCnephrology,2016
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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
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Asystematic review on conservative care
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RoleofsupportivecareinadvancedCKDmanagement
Aggressivetreatment Bereave-ment
Supportivecare
Time
DialysisTransplantAccessSurgeryAntibiotics
PaincontrolSymptomcontrolPsycho-socialsupportAwarenessofpatientgoalsandconcerns
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Withdrawalofdialysis:EuropeanNephrologistsperceptions
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Percentageofpatients withdrawn fromdialysis overthelast12months
Polltheaudience
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58,6
36,4
4,10,9
<1% 1-5%6-10% >10%
Percentageofpatients withdrawn fromdialysis overthelast12months
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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
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Physician perception oflegal backgroundofdialysis withdrawal
PanelB
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Physician perception oflegal backgroundofdialysis withdrawal
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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
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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
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0 5 10 15 20 25 30 35 40 45
don'tknow
morePCspecialistswereavailable
nephrologists hadmoreexpertiseinPC
betterlogisticalserviceswereavailable
Ibelievemorepatientswouldoptforwithdrawalif
Polltheaudience
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0 5 10 15 20 25 30 35 40 45
don'tknow
morePCspecialistswereavailable
nephrologists hadmoreexpertiseinPC
betterlogisticalserviceswereavailable
Ibelievemorepatientswouldoptforwithdrawalif
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CaringvsCuring
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Caring:compassion,respectandconcernfortheother
vsCuring:biomedicalintervention
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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
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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
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Question3• Yousufferfromanincurabledisease.Whomwouldyouprefertohaveonyourbedside
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Question3• Yousufferfromanincurabledisease.Whomwouldyouprefertohaveonyourbedside– A:theworldauthorityforthatdisease
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Question3• Yousufferfromanincurabledisease.Whomwouldyouprefertohaveonyourbedside– A:theworldauthorityforthatdisease– B:yourbestfriend
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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
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RRTatICU:acostutilityanalysis
Laukkanenetal,IntensiveCareMedicine,2012
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Wheredowewanttogo...• Limit(restrict)accesstocure
•
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Wheredowewanttogo...• Limit(restrict)accesstocure
• onwhichgrounds?• comorbidity
•
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Wheredowewanttogo...• Limit(restrict)accesstocure
• onwhichgrounds?• comorbidity,
•
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Wheredowewanttogo...• Limit(restrict)accesstocure
• onwhichgrounds?• comorbidity,age,
•
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Wheredowewanttogo...• Limit(restrict)accesstocure
• onwhichgrounds?• comorbidity,age,diabetes,...color...
•
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Wheredowewanttogo...• Limit(restrict)accesstocure
• onwhichgrounds?• comorbidity,age,diabetes,...color...sexualorientation...
•
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Wheredowewanttogo...• Limit(restrict)accesstocure
• onwhichgrounds?• comorbidity,age,diabetes,...color...sexualorientation...
•
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Thesis
Weinvesttoomuchmedical-technical(CURE)attentiontoveryfrail
patientsattheexpenseoftheCAREforthem
àndattheexpenseofthesewhowouldREALYbenefit.
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Probability ambiguity
complexity
DialysetoliveNot
Livetodialyse
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Mindfullpractice:
Tocuresometimes,torelieveoften,tocarealways