Managing Chronic Kidney Disease in Older Adults

Nashville—Chronic kidney disease (CKD) is pervasive in the older population. Geriatric patients are vulnerable to multiple intrinsic and extrinsic sources of renal injury. The progression of CKD can have a significant affect on the overall prognosis of a geriatric patient. Therefore, early diagnosis, systematic assessment, and an appropriate, patient-centered care plan are crucial to geriatric management of CKD.

During an educational session at the AMDA conference, a panel of experts discussed CKD in the older population and current trends in geriatrics.

The National Kidney Foundation Disease Outcomes Quality Initiative Workgroup has defined CKD as the following criteria, which have been accepted internationally:
• Kidney damage for ≥3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate (GFR), manifested by either pathological abnormalities; or markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests (Table)
• The presence of GFR <60 mL/min/1.73 m² for ≥3 months with or without other signs of kidney damage

Kenya Rivas, MD, opened the session with a discussion of the epidemiology and clinical manifestations of CKD in older adults. In the United States, 20 million adults have CKD. Diabetes is the leading cause of end-stage renal disease and accounts for nearly 45% of new cases of kidney failure in the United States. Almost half of the population ≥65 years of age will have moderate impairment of kidney function. Prevalence of CKD in people >60 years of age increased from 19% to 25% in the past decade. Forty percent of older adults with diabetes are at stage 1 and stage 2 CKD, according to Dr. Rivas.

The economic burden of treating CKD in this patient population is also significant. Dr. Rivas cited a study by Honeycutt et al published in 2013 in Journal of the American Society of Nephrology that examined medical costs associated with different stages of CKD among Medicare beneficiaries. The findings showed that the annual per person cost attributable to CKD is $1700 for stage 2, $3500 for stage 3, and $12,700 for stage 4, adjusted to 2010 US dollars.

“Reduced kidney function is 1 of the major factors associated with unsuccessful aging in older adults,” said Dr. Rivas.

Clinical Manifestations
Dr. Rivas also addressed the clinical presentation of kidney disease. The first hint of kidney disease may be seen on a screening urinalysis with asymptomatic abnormalities, such as hematuria, proteinuria, pyuria, and casts. Although it is not clear that age alone is a risk factor for CKD, the comorbidities associated with the aging process, including vascular disease, diabetes mellitus, and cardiac disease, places older adults at increased risk for renal problems.

Presentation of kidney disease in older and younger adults is not significantly different. Dr. Rivas noted that it is important for clinicians to recognize a decline in kidney function to permit early diagnosis of treatable causes of renal insufficiency. Diabetes mellitus is the most common cause of CKD, and diabetic neuropathy is the leading cause of end-stage renal disease, accounting for 1 in every 3 patients who enter dialysis or transplantation programs. Evaluation for proteinuria is recommended for those who have a good prognosis.

Acute Kidney Injury (AKI)
Hady Masri, DO, continued the session with a focus on AKI in older adults. Because the older population is the fastest growing segment in the general public, the increased incidence of AKI is higher worldwide. It has been shown that in older adults, both CKD and AKI are often superimposed and that recovery is less successful compared to AKI alone.

Diagnosis and treatment of AKI is crucial; however, “There is a lack of uniform definition criteria, which may be a problem with it being well-assessed,” said Dr. Masri. “The evaluation and management of
patients with AKI requires attention to cause and stage of AKI, as well as factors that relate to further injury to the kidney, or complications from decreased kidney function,” according to the 2012 “Kidney Disease: Improving Global Outcomes” clinical practice guidelines for AKI. Dr. Masri said the guidelines recommend that clinicians evaluate patients 3 months after AKI for resolution, new onset, or worsening of preexisting AKI.

Management of End-Stage Renal Disease
Elizabeth Hames, DO, rounded out the discussion by addressing management of end-stage renal disease in older adults. End-stage renal disease is less common among older adults than earlier stages of CKD; however, the number of patients ≥65 years of age with end-stage renal disease has nearly doubled in the past 25 years. Among older adults, the fastest growing population of patients with end-stage renal disease is those ≥75 years of age, she said.

There are 2 generalized approaches to the management of kidney failure. Renal replacement therapy, a disease-orientated model, factors length of survival as the most important outcome. This model also assumes direct cause and effect relationship of renal pathophysiology and patient signs and symptoms. Medical management, an individualized patient-centered approach, focuses on modifiable outcomes related to patient preferences, quality of life, and symptom management. This approach also recognizes complex comorbidities and geriatric syndromes as causes of overlapping symptoms. Furthermore, disease-specific goals can still be incorporated.

The American Society of Nephrology recommends shared decision-making before initiating and withdrawing dialysis. Older adults with multiple comorbidities and geriatric syndromes may not be appropriate candidates for dialysis, said Dr. Hames.

Prognostic tools are available for shared decision-making to guide selection of older patients for dialysis. For example, the Multidimensional Prognostic Index stresses the importance of functional status when planning treatment. Scoring is based on comprehensive geriatric assessment. A study conducted by Pilotto et al published in 2010 in Journal of Nephrology found that this tool had a significantly higher prognostic ability for 1-year mortality than estimated GFR when applied to older, hospitalized CKD patients. The Frail Renal Phenotype is another prognostic tool. It is an integrated approach that combines geriatric risk factors, comorbidity information, and survival data.

“Comprehensive geriatric assessment and shared decision-making is the best option for individualized, patient-centered care,” said Dr. Ames.—Eileen Koutnik-Fotopoulos