Aging and renal diseases - Clinical management, treatment, ethics and complications

Transcription

1 ... Aging and renal diseases - Clinical management, treatment, ethics and complications Gijs Van Pottelbergh (ACHG KULeuven, IRSS UCLouvain), Pierre Wallemacq and Jan Degryse

2 Overview Is there a high prevalence of CKD in older persons? Evolution/complications of CKD in older persons Diagnosis of CKD in older persons Treatment of CKD in older persons Ethical considerations Care trajectories.

3 Study cohorts 3

4 Prevalence of CKD in Flanders based on mean of two egfr s (MDRD) (n=34,668) 100% men 100% women 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% <30 ml/min (Stage 4+5) ml/min (stage 3B) ml/min (stage 3A) >60 ml/min (stage 0-2) Van Pottelbergh G. The prevalence of chronic kidney disease in a Flemish primary care morbidity register. Age Aging 2011

5 Causes of this high prevalence of CKD in old people 1. Age related decline ( Physiologic ) 2. Effect of toxins and diseases ( Pathologic ) 3. Adaptation (cardio-renal syndrome) 4. Diagnostic test

6 Medical science has made such tremendous progress that their is hardly a healthy human left Aldous Huxley

7 Age related decline? At age % or 43% has egfr >60 ml/min/1.73m²

8 Physiologic vs Pathologic? Data from HUNT 2 study, (1.027/ patients)

9 Causes of CKD Hallan Nephron Clin Pract. 2010;116(4):c307-16

10 Evolution of the egfr Number of patients in each stage of CKD at baseline % of patients aged 50 years and older in each stage of CKD at last measurement (mean follow up 7,8 years) ml/min ml/min (stage 3B) (stage 4) > 60 ml/min ml/min (stage 3A) < 15 ml/min (stage 5) > 60 ml/min Male (n =10,028) 88,7% 8,7% 2,0% 0,5% 0,1% Female (n = 9,903) 84,3% 12,3% 2,8% 0,6% 0,1% ml/min (stage 3A) ml/min (stage 3B) ml/min (stage 4) Male (n = 1,074) 32,6% 45,1% 18,3% 3,6% 0,4% Female (n = 2,674) 37,2% 43,6% 15,6% 3,2% 0,4% Male (n = 226) 6,6% 18,1% 47,3% 22,6% 5,3% Female (n = 614) 7,2% 24,1% 44,5% 21,7% 2,6% Male (n = 49) 4,1% 8,2% 12,2% 53,1% 22,4% Female (n = 113) 2,7% 1,8% 18,6% 52,2% 24,8% The evolution of renal function and the incidence of end stage renal disease in patients aged 50 and older, Nephrol Dial Transplant. Epub 2011 november 18

11 Evolution Evolution Of the Kidney (towards ESRD/RRT) Mortality / cardiovasculair Events complications related to CKD

12 Age and evolution of the egfr Incidence of end stage renal disease (ESRD) Baseline egfr Age group at baseline Number of patients Total years at risk Number of patients developing ESRD Incidence of ESRD per 100 patientyears Adjusted hazard ratios* (95% CI) ml/min years ,56 1 (stage 3B) years ,13 0,70 (0,62-0,78) 80+ years ,20 0,52 (0,43-0,61) ml/min (stage 4) years , years ,36 0,58 (0,41-0,75) 80+ years ,94 0,30 (0,23-0,37) * adjusted for pathology (diabetes, hypertension, high total cholesterol and high LDL cholesterol) and gender

13 Comorbidity and evolution towards ESRD Diagnosis hypertension (HR: 1,20) Diagnosis diabetes (HR: 1,25) LDL > 115 mg/dl (HR 1,28) Total cholesterol > 190 mg/dl (HR: 1,39)

14 Albuminuria and ESRD Data from HUNT 2 study, Hallan Nephron Clin Pract. 2010;116(4):c307-16

15 egfr at age 85 and mortality egfr >60 egfr ml/min/1.73m² ml/min/1.73m² (n=169) (n=147) Uncorrected Hazard ratio s (95% CI) egfr <45 ml/min/1.73m² (n=62) P (trend) Total mortality ( ) 1.30 ( ) 0.32 Cardiovascular mortality ( ) 1.74 ( ) 0.09 Non- Cardiovascular mortality ( ) 1.10 ( ) 0.97 Hazard ratio s (95% CI) corrected for possible confounders* Total mortality ( ) 1.45 ( ) 0.18 Cardiovascular mortality ( ) 2.15 ( ) 0.03 Non- Cardiovascular mortality ( ) 1.14 ( ) 0.92

16 egfr slope and total mortality

17 egfr slope and CV mortality

18 egfr slope and CV morbidity Table 3: Risk of an incident CV event during follow-up, hazard ratios (HR) and 95%- confidence intervals (95% CI) per egfr slope category (in ml/min/y) egfr slope ] 1.87] 1.87] 3.00] 1.44 [ ] 1.37 [ ] 1.38 [ ] (-5.00,- (-3.00,- 1.00] 1.20 [ ] 1.19 [ ] 1.19 [ ] (-1.00,1.00] (1.00,3.0 0] ] ] ] (3.00,5.0 0) ] ] ] HR Model [1.40- [0.81- [0.82- [ ] 1.00 HR Model [1.29- [0.84- [0.85- [ ] 0.99 HR Model [1.29- [0.84- [0.84- [ Adjusted for age and gender 2 Adjusted for age, gender, hypertension, diabetes, and CV event history 3 Adjusted for age, gender, hypertension, diabetes, CV event history and baseline kidney function (here is the last measurement) 1.21]

19 CKD-related complications 19

20 CKD-related complications 90 % of Complications in function of MDRD low HB high PTH high Phosphate low Ca >60 (305) (126) (74) <30 (31) 20

21 CKD-related complications Treatment General same as other persons BUT Co-morbidity (heart failure, dementia, ) and polymedication Care planning Many formal and informal caregivers involved 21

22 Diagnosis of CKD in older persons.

23 Diagnosis: Problems with egfr estimations in older people Serum creatininine depends on muscle mass - Age, gender and race - Chronic disease - Fysical activity - Medication use Large variation in muscle mass and physical activity in the (very) elderly

24 Differences between egfr estimations Belfrail study, representative sample of 544 patients aged 80 and older divided into stages of CKD based on egfr s Total matches Match <30 ml/min Difference <10% Difference 10 20% Difference 20 30% Difference >30% CG-MDRD 277 (51.7%) 27/60 (45%) 9.9% 22.8% 27.2% 40.1% MDRD-CKDEPI 517 (96.5%) 31/38 (82%) 52.1% 39.3% 6.5% 2.0% MDRD CystC 371 (69.2%) 21/42 (50%) 22.9% 25.4% 18.2% 21.9% CystC CG 267 (49.8%) 23/60 (38%) 22.9% 21.8% 17.7% 37.5% CystC CKDEPI 369 (68.8%) 23/47 (49%) 31.7% 28.9% 18.7% 20.6% CKDEPI CG 294 (54.8%) 33/57 (58%) 32.6% 29.9% 26.3% 11.2% Van Pottelbergh Age and Ageing, 2011, 40 (3), 401-5

25 Classification of CKD in older people Do all elderly persons with egfr< 60 ml/min have CKD? Pathologic vs fysiologic in oldest old? When do we call something a disease? Some facts concering older people with egfr ml/min No more CKD-related complications (Belfrail data under publication) No higher cardiovasculair or total mortality in the very elderly Low chance of evolution towards ESRD (<0,1%/year)

26 Diagnosis of CKD in older persons Lower GFR in the oldest old is the result of aging related physiological changes and pathological damage in the (very) elderly large differences between the currently used equations and the true GFR No simple classification for the diagnose of CKD but look at Evolution of the egfr over time Albuminuria Age and general condition of the patient Comorbidity CKD-related complications

27 Relevant guidelines Belgian Aanbeveling CNI (2012) Belgian Multidisciplinaire richtlijn Chronisch nierlijden (CNI) 2016 Aanvulling op de richtlijn Chronische nierinsufficie ntie van Domus Medica, 2012 International: NICE and KDOQI

28 Treatment of CKD - Give RAAS inhibition when proteinuria/albuminuria - Treat complications - Treat underlying ethiology like diabetes - Prevent new damage - Lifestyle - CV risk reduction: BP, chol, - Drug use - Contrast use

29 Treatment of CKD in older persons Multimorbidity and poly-pharmacy Shorter life expectancy, more focus on quality of life Care planning Less or no hard evidence

30 Drug use in older persons Many guidelines and sources Often just general recommandations 30

31 Drug use in older persons Drug (frequency) egfr (MDRD) (ml/min/1.73 m²) Possible effect(s) Participants with inappropriate drug use Metformine (n=46) Increased risk for lactate acidosis 13 < 30 Strongly increased risk for lactate acidosis 2 Gliclazide (n=15) < 50 Increased risk for hypoglycaemia 8 Tramadol (n=34) < 30 More side-effects when DD >200 mg/d 0 Paracetamol (n=61) < 50 More side-effects when DD > 1500 mg/d 7 Spironolactone (n=22) < 50 Increased risk for hyperkalaemia 10 Sotalol (n=17) More side-effects when DD >160 mg/d 0 < 30 More side-effects when DD > 80 mg/d 0 Atenolol (n=30) < 30 More side-effects 2 Ranitidine (n=35) < 30 More side-effects 3 Allopurinol (n=37) More toxic side-effects when DD >200 mg 8 < 30 More toxic side-effects when DD >100 mg 3 31

32 Ethical considerations - Start RRT or not in frail elderly? - No clear benefit on survival of dialysis - Many complications and drop outs - High cost (Quality of life and financial)

33 Shared decision making Informed and empowered patiënt/relatives are needed What happens if no dialysis What happens if dialysis: side-effects, transport, complications No life prolonging effect of dialysis Needs at least 2 sessions Neutral information Multidisciplinair in geriatric patient No good or bad decissions, only equal options

34 Advanced care planning Continous proces Takes time (2-3 sessions at least) Often with relatives Can be changed at any time Goal setting instead of medical paternalism Comfort of the patient often crucial not survival

35 Care trajectories

36 CNI IN FLANDERS: PERSONS By stage 1% Stadium 3A Stadium 3B Stadium 4 Stadium 5 by "trajectory Geen Zorgtraject Post transplant Dialyse 2%0%1% 10% 26% 63% 97% 36

37 Care trajectories Van Pottelbergh, G., Degryse, J. (2013). An alternative classification system for chronic kidney. BMJ Journal, 347, art.nr /bmj.f5566, Van Pottelbergh, G. (2012). betere criteria voor inclusie in het zorgtraject chronishce nierinsufficiëntie: een kritische noot. Tijdschrift voor Geneeskunde, 68 (12), G. Van Pottelbergh, N. Demoulin, M. Jadoul, K. Claes, J. Degryse Des critères d inclusion plus adéquats pour le trajet de soins insuffisance rénale chronique. Une note critique concernant le trajet de soins Louvain Med. 2011; 130 (9):

38 Conclusions regarding CKD in the oldest old - More then just the egfr: - egfr evolution, - comorbidity, - proteinuria, - complications, - Individual goal setting with patients and multidisiplinary team essential in ESRD - Need for new inclusion-criteria for the CKD care trajectory for the oldest old.

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