Renal replacement therapy and the Renal replacement therapy and the elderly.elderly.

Misha Kotlov, MD Misha Kotlov, MD

July 10, 2007July 10, 2007

Demographics.Demographics.

► In the In the USUS, the primary treatment of geriatric ESRD , the primary treatment of geriatric ESRD patients (patients (>> 75 75 yrsyrs) is in-center hemodialysis (96) is in-center hemodialysis (96 % %))

► CAPD/CCPD account for approximately 3.5 CAPD/CCPD account for approximately 3.5 %%► The average age of the patient undergoing dialysis The average age of the patient undergoing dialysis

in the in the US US has been steadily increasingly over the has been steadily increasingly over the last several decades.last several decades.

► In 2000In 2000 the average age was approximately 62 the average age was approximately 62 yyrsrs..► According to According to United States Renal Data System United States Renal Data System

database, the number of patients database, the number of patients > > 80 yrs of age80 yrs of age who initiated dialysis increased from 7054 patients who initiated dialysis increased from 7054 patients in 1996 to 13,577 individuals in 2003in 1996 to 13,577 individuals in 2003..

Issues at hand.Issues at hand.

► Important points to consider when Important points to consider when evaluating the treatment of elderly patients evaluating the treatment of elderly patients with ESRD include:with ESRD include:

► LLife expectancy of such patients ife expectancy of such patients ► EEffect of ESRD on life expectancy and ffect of ESRD on life expectancy and

quality of life quality of life ►HD vs PDHD vs PD► Timing of access placementTiming of access placement

Effect of Age, Gender, and Diabetes on Excess Effect of Age, Gender, and Diabetes on Excess Death in ESRD. Death in ESRD. JASN 18:2125-2134, 2007JASN 18:2125-2134, 2007

►All incident dialysis patients between All incident dialysis patients between January 1999-December 2003 in January 1999-December 2003 in Rhone-Alpes region, France.Rhone-Alpes region, France.

►3025 patients were analyzed.3025 patients were analyzed.►Age and gender standardized mortality Age and gender standardized mortality

ratio (SMR) was computed in ESRD vs ratio (SMR) was computed in ESRD vs general population of the region.general population of the region.

►Overall and by patient subgroups.Overall and by patient subgroups.

► Population 6 million.Population 6 million.► Rhône-Alpes is located in Rhône-Alpes is located in

the east of France. The the east of France. The east of the region east of the region contains the western contains the western part of the Alpart of the Alps. ps. The The highest peak is Mont highest peak is Mont BlaBlancnc. The central part of . The central part of the region is taken up the region is taken up with the valley of the with the valley of the Rhône and the Saône. Rhône and the Saône. The confluence of these The confluence of these two rivers is at Lyontwo rivers is at Lyon, the , the capital of the region.capital of the region.

““There are three kinds of lies: lies, damned lies, and There are three kinds of lies: lies, damned lies, and statisticsstatistics.”.”

Benjamin Disraeli, Prime Minister of England end of 19 Benjamin Disraeli, Prime Minister of England end of 19 century.century.

► Standardized Mortality RatioStandardized Mortality Ratio► SMRSMR = Observed Deaths / Expected Deaths = Observed Deaths / Expected Deaths► Excess DeathsExcess Deaths = Observed Deaths - Expected Deaths = Observed Deaths - Expected Deaths► Charlson IndexCharlson Index contains 19 categories of contains 19 categories of

comorbidity, which are primarily defined usingcomorbidity, which are primarily defined using ICD-9- ICD-9-CM diagnoses codes.CM diagnoses codes.

► Each category has an associated weight, which is Each category has an associated weight, which is based on the adjusted risk of one-year mortality. based on the adjusted risk of one-year mortality.

► The overall comorbidity score reflects the cumulative The overall comorbidity score reflects the cumulative increased likelihood of one-year mortality; the higher increased likelihood of one-year mortality; the higher the score, the more severe the burden of the score, the more severe the burden of comorbidity. comorbidity.

Characteristics of study population.Characteristics of study population.

► Total cohort 3025 Total cohort 3025 patients.patients.

► Age 75-84: n=719; Age 75-84: n=719; >85: n=139>85: n=139

►Gender ration (m/f) Gender ration (m/f) = 1.7= 1.7

► 75 % of pt >75 75 % of pt >75 were treated with were treated with HD.HD.

SurvivlSurvivlal %al %

TotalTotal 75-84 75-84 yrsyrs

>85>85

1 yr1 yr 8282 6969 5959

2 yr2 yr 7070 5050 3939

3 yr3 yr 6262 3737 2323

4 yr4 yr 5555 2626 1212

5 yr5 yr 4848 1818 99

SMR SMR inin ESRF ESRF versusversus GP of the same age and GP of the same age and the same genderthe same gender..

Kaplan-Meier survival curves by age group and

standardized mortality ratios by age group.

Octogenerians and nonagenarians starting Octogenerians and nonagenarians starting dialysis in the US.dialysis in the US.

Ann Intern Med 146:177-183, 2007Ann Intern Med 146:177-183, 2007►USRDS Standard Analysis Files from 1996

through 2003 for these analyses.► Included all persons 65 years of age and

older who began dialysis between 1 January 1996 and 31 December 2003 (n=350,831).

►The focus of these analyses was the very elderly;

► Included patients 65 to 79 years of age (the “young” elderly) in the analyses as a reference group.

►Excluded patients initiating dialysis after a failed kidney transplantation (n=4,693)

Incidence of dialysis initiation.Incidence of dialysis initiation.

Trends in dialysis initiation.Trends in dialysis initiation.► 1996-2003, 78,419 octogenarians and 5,577 nonagenarians

initiated dialysis in the United States.► 7,054 pts in 1996 13,577 pts in 2003: average annual

increase 8.6%(2.3%) in 80-84 yrs and 11.9%(3.2%) > 85 yrs.► Annual increase in dialysis initiation among patients 65-79 yrs

was 3.5%(0%). ► Accounting for population growth, rates of dialysis initiation

increased by 57% among octogenarians and nonagenarians from 1996 to 2003.

► For persons older than 84 years of age, rates of dialysis initiation were dramatically lower than other elderly age groups; this effect persisted over time.

Survival.Survival.

Survival.Survival.

► One year mortality rate for octogenarians and nonagenarians starting dialysis was 46% and did not change over the 7-year period.

► Associated clinical characteristics: nonambulatory status, low serum albumin concentration, congestive heart failure, and underweight were most strongly associated with death.

Age Age group,group,

yrsyrs

Median Median survival, survival, momo

Average Average life life expectancexpectancy, moy, mo

65-7965-79 2525 ??

80-8480-84 1515 105105

85-8985-89 1212 7575

>90>90 88 5757

Comparison and Survival of HD and PD in the Comparison and Survival of HD and PD in the elderly. Seminars in Dialysis 15:2:98-102, elderly. Seminars in Dialysis 15:2:98-102,

20022002► Inclusion: Initiated dialysis during the years 1995±1997, >67

yrs at the time of initiation. (N=89,193). ► Source: Medicare claims. ► Dialytic modality: Determined on day 90 of ESRD care, >60

days on this modality.► After excluding all pts with missing info: N=70,208; 6,695

(10%) on PD and 63,513 (90%) on HD► Interval Poisson regression was used to calculate adjusted

death rates and relative risks between the PD and HD populations.

► Analyses were adjusted for age, gender, race , geographic location (six groups of renal networks), Charlson comorbidity index score, baseline GFR, prior hospital days, incidence year (1995, 1996, 1997), and primary cause of renal failure (diabetes, hypertension, GN, other).

► Separate analyses were performed for the diabetic and nondiabetic populations.

Table 1.Table 1.

Relative risk of death.Relative risk of death.

Death rates per 1000 patient years

Interval death rates DM and non-DM.

Interval relative risks (HD:PD) of death for Dm vs non-DM.

The longer, the better?The longer, the better?

► 12 month prospective cohort study of outcomes in 221 12 month prospective cohort study of outcomes in 221 patients with ESRD, started on HD, age >70 yrs.patients with ESRD, started on HD, age >70 yrs.

► Recruted from 4 hospital based dialysis units.Recruted from 4 hospital based dialysis units.► Quality of life was assessed by interview at 90 days after Quality of life was assessed by interview at 90 days after

initiation of HD in new patients and at 5 months to 10.8 yrs in initiation of HD in new patients and at 5 months to 10.8 yrs in chronic patients. chronic patients.

► SF-36 physical component summary (PCS) and mental component summary (MCS) scores were calculated;

► High scores indicate good quality of life. ► SF-36 scores were compared with UK general population

norms for people 70 years or over and US norms for adults aged 65–74 and 75 years or over.

Lancet 2000Lancet 2000

Dismal rehabilitation in geriatric inner-city Dismal rehabilitation in geriatric inner-city hemodialysis patientshemodialysis patients..

E. Freidman et al. JAMA 1994E. Freidman et al. JAMA 1994► CCohort study of elderly patients who have end-stage ohort study of elderly patients who have end-stage

renal diseaserenal disease..► CCurrent status was compared with patient's urrent status was compared with patient's

recollection of functional activity level 2 years before recollection of functional activity level 2 years before commencing maintenance hemodialysis. commencing maintenance hemodialysis.

► Seven outpatient, hospital-affiliated and private Seven outpatient, hospital-affiliated and private hemodialysis units in Brooklyn, NY. hemodialysis units in Brooklyn, NY.

► 104104 patients aged 65 years or older who were patients aged 65 years or older who were receiving maintenance hemodialysis for at least 6 receiving maintenance hemodialysis for at least 6 months.months.

► Measured outcome: Measured outcome: A score of 76 or greater on a A score of 76 or greater on a modified Karnofsky scale indicated independent modified Karnofsky scale indicated independent function at a level that permitted participation in function at a level that permitted participation in activities beyond those mandated by the activities beyond those mandated by the hemodialysis regimen. hemodialysis regimen.

Karnofsky performance scale.Karnofsky performance scale. ► 100% - normal, no complaints, no signs of disease 100% - normal, no complaints, no signs of disease ► 90% - capable of normal activity, few symptoms or signs of 90% - capable of normal activity, few symptoms or signs of

disease disease ► 80% - normal activity with some difficulty, some symptoms or 80% - normal activity with some difficulty, some symptoms or

signs signs ► 70% - caring for self, not capable of normal activity or work 70% - caring for self, not capable of normal activity or work ► 60% - requiring some help, can take care of most personal 60% - requiring some help, can take care of most personal

requirements requirements ► 50% - requires help often, requires frequent medical care 50% - requires help often, requires frequent medical care ► 40% - disabled, requires special care and help 40% - disabled, requires special care and help ► 30% - severely disabled, hospital admission indicated but no 30% - severely disabled, hospital admission indicated but no

risk of death risk of death ► 20% - very ill, urgently requiring admission, requires 20% - very ill, urgently requiring admission, requires

supportive measures or treatment supportive measures or treatment ► 10% - moribund, rapidly progressive fatal disease processes 10% - moribund, rapidly progressive fatal disease processes ► 0% - death. 0% - death.

Results.Results.

► Karnofsky score Karnofsky score deteriorated to average deteriorated to average of 66 compared with of 66 compared with patients' recollection of a mean score of 8patients' recollection of a mean score of 84 4 (P < .001) 2 years (P < .001) 2 years before initiation of hemodialysis. before initiation of hemodialysis.

► Diabetic patients had a lower score than nondiabetic patients. Diabetic patients had a lower score than nondiabetic patients. ► Within the diabetic subset, severe debility constrained 71 Within the diabetic subset, severe debility constrained 71

patients (68%) to limit all activity to their residence with the patients (68%) to limit all activity to their residence with the exception of travel to and from their dialysis facility. exception of travel to and from their dialysis facility.

► 2 years prior to commencing dialytic therapy, 81 diabetic 2 years prior to commencing dialytic therapy, 81 diabetic patients (78%) had interests and activities that took them patients (78%) had interests and activities that took them outside their homes (P < .001). outside their homes (P < .001).

► CONCLUSIONSCONCLUSIONS: : Maintenance hemodialysis does not return Maintenance hemodialysis does not return inner-city elderly patients to their predialysis level of inner-city elderly patients to their predialysis level of functioning. Few elderly, diabetic hemodialysis patients functioning. Few elderly, diabetic hemodialysis patients conduct any substantive portion of their lives outside their conduct any substantive portion of their lives outside their homes. homes.

When to refer patients with chronic kidney disease

for vascular access surgery: Should age be aconsideration? KI 71:555-561,2007

► Retrospective cohort study among 11,290 non-dialysis patients with aneGFR of 25 ml/min/1.73m2 based on 2000–2001 outpatient creatinine measurements in the Department of Veterans Affairs.

► ► For each age group, the percentage of patients that had and had

not received a permanent access by 1 year after cohort entry, and the percentage in each of these groups that died, started dialysis, or survived without dialysis was established.

► Modeled the number of unnecessary procedures that would have occurred in theoretical scenarios based on existing vascular access guidelines.

► The mean eGFR was 17.7 ml/min/1.73m2 at cohort entry. ► Mean age of the patient cohort was 70 yrs.► 25% (n=2870) of patients initiated dialysis within a year of cohort

entry.► Only 39% (n=1104) had undergone surgery to place a permanent

access beforehand.

Permanent vascular access surgeries by age Permanent vascular access surgeries by age group.group.

A Percent of all cohort patients who received pre-dialysis permanent access by the end of follow-up. Estimates are provided with a 95% confidence interval.B Percent of patients who initiated dialysis during follow-up that had undergone permanent access placementbefore initiation of dialysis. Estimates are provided with a 95%confidence interval.

One year outcome by age group.One year outcome by age group.

Ratio of unnecessary to necessary permanent access surgeries at different theoretical referral eGFR

thresholds by age and length of follow-up.

a Referral threshold eGFR=25 b Referral threshold eGFR=20c Referral threshold eGFR=15

Conclusion.Conclusion.

► Rates of initiation of dialysis in elderly is Rates of initiation of dialysis in elderly is increasing: increase ckd prevalence, earlier increasing: increase ckd prevalence, earlier initiation of dialysis, more liberal acceptance initiation of dialysis, more liberal acceptance in dialysis programs.in dialysis programs.

► Dialysis can significantly prolong life in elderly Dialysis can significantly prolong life in elderly population.population.

► Elderly seem to do better on HD vs PD.Elderly seem to do better on HD vs PD.► QOL: more studies needed.QOL: more studies needed.► Access: when should avf/avg be placed in Access: when should avf/avg be placed in

elderly ?elderly ?