Dialysis in the elderly and frail patients. Angel LM de Francisco. Hospital Marqués de Valdecilla. Santander

Transcription

1 Dialysis in the elderly and frail patients Angel LM de Francisco. Hospital Marqués de Valdecilla. Santander

2 Incidence of RRT per million age related popula4on in 2014 by age group The incidence PMARP was defined as the number of patients starting RRT annually divided by the mid-year general agerelated population Profit vs. non-profit haemodialysis facilities, Pre-dialysis treatment Competing mortality Home care facilities Jaakko Helve 1,2, Anneke Kramer 3, Carola Grönhagen- Riska 1,.,Ki>y J. Jager 3, Patrik Finne1,2 (in press)

3 The good physician treats the disease. The great physician treats the patient who has the disease Sir William Osler.

4 Fundamental goals of Medicine Besides curing disease, the fundamental goals of medicine include the relief of suffering, treatment of symptoms, especially pain, maintenance of quality of life, communication about prognosis, and avoidance of harm

5 82 years Prostatic cáncer pelvic metástasis (January 2010) CKD 5 no dialysis 3 years Conservative therapy 5 3y 6,7

6 Dialysis in the elderly and frail pa4ents Aging Frailty Frailty in dialysis pa4ents Frailty in dialysis: can be reversed? Conserva4ve treatment

7 Size of the older population in the world The size of the older population in the world is increasing, with the global population of those aged 65 years set to double by : 901 million 2050: 2.1 billion

8 Spain population over 65 years,

9 Aging Dialysis Population Europe: 20-45% incident dialysis > 75 years old (ERA/EDTA Registry2013) Canada 35% Australia highest incidence years

10 PREVALENT patients in Dialysis: Mean Age Cantabria (Spain) Edad '00 '01 '02 '03 '04 '05 '06 '07 '08 '

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12 BiomedicalizaMon of aging

13 Dialysis in the elderly and frail pa4ents Aging Frailty Frailty in dialysis pa4ents Frailty in dialysis: can be reversed? Conserva4ve treatment

14 Why are some very old people able to run marathons, whereas others, even without major comorbidities, have marked functional decline? Is not ageing per se but the association between ageing and frailty

15 What Is Frailty? A medical syndrome with multiple causes and contributors that is characterized by diminished strength, resistency, and reduced physiologic function that increases an individual s vulnerability for developing increased dependency and/ or death Aging and chronic diseases Oxidative stress Inflammation Reductions in anabolic hormones Frailty Morley JE, et al Frailty consensus: a call to action. J Am Med Dir Assoc 2013; 14:

16 Potential causes of frailty and protein-energy wasting in elderly patients with end stage kidney disease. Frailty is associated with oxidative stress, inflammation, and reductions in anabolic hormones Jun Chul Kim et al. JASN 2013;24: by American Society of Nephrology

17 Domains and criteria for the Fried model of frailty 3 or more of : Shrinking Unintentional weight loss of >4.5 kg (>10 lb) in the previous year Weakness Grip strength in the lowest 20% of the population Exhaustion Self-reported exhaustion, according to the Center of Epidemiological Studies e depression scale Slowness A 15-feet (4.6-m) gait speed falling in the slowest 20% of the population Low activity Values for kcal/week burned in the lowest 20% of the population Key domains of frailty include physical function, nutritional status, mental health and cognition Fried L, et al J Gerontol A Biol Med Sci 2004; 59:

18 Domains and criteria for the Fried model of frailty Gait speed <0.8 m/s; 5m timed-up-and-go test >10s and PRISMA 7 questionnaire 3 can indicate frailty

19 PRISMA 7 QuesMonaire Gait speed <0.8 m/s; timed-up-and-go test >10s and PRISMA 7 questionnaire 3 can indicate frailty

20 Prevalence of Frailty in the Dialysis Popula4on differences in the method of assessing frailty, dialysis vintage or degree of comorbidity contribute to the variation Kirsten L. Johansen Blood Purif 2015;40:

21 1 Dialysis population is aging with a high proportion of frail individuals

22 Dialysis in the elderly and frail pa4ents Aging Frailty Frailty in dialysis pa4ents Frailty in dialysis: can be reversed? Conserva4ve treatment

23 The effects of frailty in dialysis pa4ents Dialysis patients (compared to cancer & HF) More hospitalisations More ICU admissions More hospital deaths (less hospice use) 29% had at least 1 life-sustaining interventions (mechanical ventilations, CPR, feeding tube insertion) Carson RC :CJASN 2009

24 The indicamon of dialysis Avoid dialysis Irreversible coma Terminal cancer Inability to tolerate the procedure????????? at risk for early mortality,increased hospitalizations, acceleration of geriatric syndromes, and significant symptom burden

25 Life expectancy by quar4le following dialysis ini4a4on according to age and renal phenotype healthy Vulnerable 0-25 Frail Tamura MK Kidney Int August ; 82(3):

26 Frailty associamon with risk of death- hospitalizamon 2275 adults who participated in the Dialysis Morbidity and Mortality Wave 2 study, Frailty was associated with >3-fold higher risk of death Also associated with fall and fractures Kirsten L. Johansen J Am Soc Nephrol 18: , 2007

27 2 Frailty is associated with shorter survival and hospitalization

28 Dialysis in the elderly and frail pa4ents Aging Frailty Frailty in dialysis pa4ents Frailty in dialysis: can be reversed? Conserva4ve treatment

29 Frailty in dialysis: can be reversed? Functional status declines further after initiation of dialysis among frail and very elderly patients without intervention Kurella et al N Engl J Med 2009;361:

30 Frailty in dialysis: can be reversed? No specific trials have yet been published to demonstrate the clinical- or costeffectiveness of interventions directed towards frailty per se, although it is likely that generic interventions such as exercise, health lifestyle and good nutrition are important.

31 Frailty in dialysis: can be reversed? Dialysis Fistula first Incremental HD or DPCA?.. Nutrition Exercice

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35 Karen Woo* et al Clin J Am Soc Nephrol 11: ,

36 Failure to mature (primary failure) of new fistulas 22% in younger men with an upper arm fistula to 78% in older women with a forearm fistula. 205 hemodialysis patients for whom preoperative mapping was obtained The overall primary fistula failure rate was 40% Peterson WJ Clin J Am Soc Nephrol 3: , 2008

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38 Patient survival by access attempt strategy. David A. Drew, J Am Soc Nephrol 26: , 2015.

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40 AV F t o x i c i t y i s d i r e c t l y proportional to access flow rate, and inversely proportional to cardiac status Blood Purif 2011; 31: 113

41 Complexities of AV access planning in a study of octogenarians Of those who had preoperative vein mapping during the predialysis period, all had AVFs created 32% died before needing to start dialysis Within the cohort, 57.5% of patients died within 18 months of starting dialysis Of these patients who died, 55.5% died within 6 months of starting dialysis: 70% of them had AVFs created, but none of the AVFs matured to allow for cannulation before the patients died Vachharajani TJ, Moossavi S, Jordan JR, Vachharajani V, Freedman BI, Burkart JM: Re-evaluating the Fistula First Initiative in octogenarians on hemodialysis. Clin J Am Soc Nephrol 6: , 2011

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45 Theoretical framework for prognosis-matched vascular access planning Murea M Seminars in Dialysis 2016

46 3 In the elderly, fistula first should be used in patients who have a high chance for a successful fistula. In circumstances where patient survival is limited by comorbidities and functional status, AVF is unlikely to confer meaningful benefits compared to AVG or even TCVC in the ill elderly. Patient first

47 Valdecilla Ø 65 years n 271 n infections 20 duration 803 days Ø 80 years n 42 n infections 1 duration 932 days

48 Incremental dialysis Prescribing a lower hemodialysis dose depending on the clearance provided by residual kidney function Wong J Nephrol Dial Transplant (2015) 30 (10):

49 Incremental dialysis (escalating the dose of dialysis as RRF declines.) Observational studies suggest that an incremental approach to HD initiation and less frequent dialysis regimes may have benefits including preservation of RRF and better patient experience due to less interruption of lifestyle Lin Y-F, Huang J-W, Wu M-S et al. Comparison of residual renal function in patients undergoing twice-weekly versus three-times-weekly haemodialysis. Nephrology (Carlton) 2009; 14: Kalantar-Zadeh K, Unruh M, Zager PG et al. Twice-weekly and incremental hemodialysis treatment for initiation of kidney replacement therapy. Am J Kidney Dis 2014; 64: Rhee CM, Unruh M, Chen J et al. Infrequent dialysis: a new paradigm for hemodialysis initiation. Semin Dial 2013; 26: Zhang M, Wang M, Li H et al. Association of initial twice-weekly hemodialysis treatment with preservation of residual kidney function in ESRD patients. Am J Nephrol 2014; 40: Teruel-Briones JL, Fernández-Lucas M, Rivera-Gorrin M et al. Progression of residual renal function with an increase in dialys

50 No clear differences in mortality, hospitaliza4on,bp and volume control Nutri4on or mineral metabolism

51 Residual renal func4on: benefits and risks Subclinical chronic fluid overload Treatment adequacy and outcomes of dialysis patients (surrogate marker of relatively good health?)

52 For many nephrologists incremental dialysis supposes a disorganization and loss of resources in the dialysis units, without clear positive results Starting dialysis before patients develop Protein Energy Wasting More than two times per week MHD treatments and larger doses of dialysis may improve patients appetite, food intake, nutritional status, and QOL and reduce frailty and PEW

53 4 Incremental dialysis in frail elderly people does not improve neither survival nor hospitalization and it is a risk for subclinical flow overload

54 Survival rates for the frail elderly are poor on any dialysis modality, and, as recent studies have shown, for those older than 80 years of age or those with poor physical function or multiple comorbidities, there may not be even any survival advantage having any type of dialysis

55 Assisted PD

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57 Frequent HD (>3 times per week) can improve LVH BP control, PRO, suggesting an improved patient perception of their QoL. Time to recovery after a dialysis session Depressive symptoms and sleep quality may Scores on the Short Form-36 How frail elderly patients will respond to more frequent treatments????? significant treatment burden increased requirement of transport

58 5 There is not clear scientific support of any dialysis technique for elderly and frail patients

59 Frailty in dialysis: can be reversed? Nutritional intake Multivitamin and trace element supplements Most expert groups recommend dietary protein intake (DPI) for adult, ranging from 1.0 to 1.3 g/kg per day with at least 50% of the DPI of high biologic value. Oral supplements of protein or primarily essential amino acids, usually including additional calories, may improve protein balance Tube feeding, intradialytic parenteral nutrition, or if necessary, total parenteral nutrition may be used for patients who are unable to take oral supplements. Kim JC JASN March 2013

60 Frailty in dialysis: can be reversed? Metabolic Acidemia KDIGO > 22meq /l Recent evidence suggests that higher ph values may be more anabolic. Anabolic Agents Recent studies indicate that testosterone or other androgenic compounds may engender muscle hypertrophy and strength in dialysis patients Carnitine also increases nitrogen balance in CPD patient GH increases muscle protein synthesis, reduces net protein catabolism, Kim JC JASN March 2013

61 6 The importance of nutritional preventive and therapeutic approaches in elderly and frail patients in dialyisis is intuitively obvious. However Nutritional support for elderly ESRD patients apparently has not been examined.

62 R placebo CT 10 weeks comparing progressive resistance exercise training, multinutrient supplementation, both interventions, and neither in 100 frail nursing home residents CONCLUSIONS: High-intensity resistance exercise training is a feasible and effective means of counteracting muscle weakness and physical frailty in very elderly people. In contrast, multi-nutrient supplementation without concomitant exercise does not reduce muscle weakness or physical frailty.

63 Aerobic physical activity 5763 patients enrolled in phase 4 of the Dialysis Outcomes and Practice Patterns Study ( ) Conclusions The findings are consistent with the health benefits of aerobic physical activity for patients on maintenance hemodialysis. Greater physical activity was observed in facilities providing exercise programs, suggesting a possible opportunity for improving patient outcomes Clin J Am Soc Nephrol 9: , 2014

64 Aerobic physical activity in frail dialysis patients The vigorous nature of such training programs has led to the exclusion of large numbers of patients on hemodialysis as ineligible High rate of patient refusal Fear or reluctance to do vigorous activity is a barrier for patients adoption of exercise programs

65 7 The clinical benefits of most preventative and therapeutic physical approaches have not been shown in large-scale clinical trials in which QOL, morbidity, and mortality are used as key outcomes. Referral of frail individuals for physical therapy and strength training (when posible) should be strongly considered when weakness or frailty is detected

66 NONDIALYTIC TREATMENT/RENAL PALLIATIVE CARE Many interventions, including dialysis, can have a considerable negative impact on the day-to-day living of individuals and their families, but yet may be of benefit in alleviating some symptoms and sometimes extending life. Given the potential distress to patients and their families as well as the cost of these interventions, it is not surprising that there is now considerable debate about quality or quantity of life for individuals with limited life expectancy Kauf F, Aaronson PS. ESRD as a window into America s cost crisis in health care. J Am Soc Nephrol. 2009;10: Vandecasteele SJ, Tamura MK. A patient-centered vision of care for ESRD: dialysis as a bridging treatment or as a final destination? J Am Soc Nephrol. 2014;25: Churchill DN, Jassal SV. Dialysis: destination or journey? J Am Soc Nephrol. 2014;25: Carson RC, Jaszczak M, Davenport A, Burns A: Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease?. Clini J Am Soc Nephrol. 2009, 4: /CJN

67 Survival in elderly ESRD patients Carson RC Clin J Am Soc Nephrol 4: , 2009

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69 Murtagh Nephrol Dial Transplant. 2007;22(7): doi: /ndt/gfm153

70 High Comorbidity (sc 2) Ischaemic heart Murtagh Nephrol Dial Transplant. 2007;22(7): doi: /ndt/gfm153

71 Comparative 1-year survival elderly 1-year survival for dialysis modalities of 84.2% and 72.7% with supportive care 3 out of four studies demonstrated loss of this survival benefit in the presence of high comorbidity Foote C

72 Hospital free days conservative versus dialysis Edad 81.6 Vs 76.4 años 13.9 m (2-- 44) 37.8 m ( ) 47.5% días que sobreviven (173 días / año) lo hacen hospitalizados o en diálisis vs 4,3% (16 días/ año). Carson RC Clin J Am Soc Nephrol 4: , 2009

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74 7 Dialysis prolongs survival for elderly patients who have ESRD; however, patients who choose conservative therapy can survive a substantial length of time, achieving less hospital-center -free days to patients who choose hemodialysis.

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77 In a recent Canadian survey, 60% of a sample said they regretted beginning dialysis, and just over half of the patients indicated they initiated treatment because of the urging of their physician In sum, only belatedly have nephrologists begun to appreciate the advancing age, substantial prevalence of symptoms, existential suffering and high mortality rates of the elderly ESRD population Davison SN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol 2010; 5: Kurella Tamura M. Incidence, management, and outcomes of end-stage renal disease in the elderly. Curr Opin Nephrol Hypertens 2009; 18:

78 I am against the current culture of applying clinical practice guidelines to all patients and challenge the benefits of using biochemical surrogate outcomes

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