Dialysis in frail and Elderly

Transcription

1 Dialysis in frail and Elderly Dr Shibu Jacob, Assistant Professor, Christian Medical College, Vellore. ISHDCON April 2,2017

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3 Complications during dialysis and soon after? How to minimise these? Should we start Chronic dialysis? What modality? When to start Chronic Dialysis? A cross section study of our elderly dialysis patients.

4 Complications during HemoDialysis Intradialytic hypotension Cognitive impairment Malnutrition Infection Gastrointestinal bleeding

5 Intradialytic Hypotension: Causes Volume Intravascular Hypovolemia Low albumin Difficult to assess dry weight. Cardiac Arrhythmogenicity Coronary insufficiency (Athero or calcific) Diastolic dysfunction Autonomic Neuropathy Vasovagal Baroreceptor deafferentation Bezold Jarisch Reflux Sympathetic dysfunction (Low venous and arterial tone)

6 Intradialytic Hypotension HD worsens all the causes of Hypotension Rapid shift of solutes DDS : Cognitive Arrhythmia Even atrial arrhythmias are important in patients with LV Dysfunction

7 Cognitive impairment - causes Dialysis Dysequilibrium Syndrome Rapid solute shift Cell swelling Demyelination Silent Infarcts worsened by hypotension Microemboli of air not removed by Air trap Anemia Accelerated Cerebral atrophy in ESRD Decreased O 2 consumption capacity

8 Malnutrition Uremia Polypharmacy/Taste Reduced GI Absorption Dental problems Frequent illness Infection/ Inflammation Post Dialysis Fatigue Postural Hypotension Cramps Not able to cook Food avoidance

9 Infections in elderly on dialysis Low immunity Age Uremia Malnutrition Catheters Poor Respiratory muscle functions Pneumonia Response to infections Cardiac deaths

10 Upper GI Bleed GI Bleed: cause Vascular ectasia Diverticuli Malignancy Use of Anticoagulants Platelet Dysfunction of uremia Low Hematocrit

11 Prevention of complications Donot Start with high efficiency Dialysers Donot use Acetate Dialysate Volume controlled, Slow Ultrafiltration Profiling : Sodium,Potassium, Bicarbonate Monitoring of calcium and Magnesium EPO to Keep good Hb Level Nocturnal, Long, Frequent Dialysis

12 Special suggestions for elderly Bio impedence monitoring to assess Dry weight Volume monitored Ultrafiltration Edematous patient with intravascular hypovolemia, Low albumin. Dry Vasculopath with Pulmonary congestion Diastolic dysfunction Ensure machine maintenance to detect variation in dialysate conductance with out fail.

13 Prevention of Malnutrition Assessment of nutritional status from pre dialysis state On dialysis Kcal/Kg/day 1 to 1.2g protein/day Intradialytic parentral nutrition Acidosis correction Alkalosis also cause nausea

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15 Age > 75 years have increased incidence of ESRD. Fastest increasing group on HD. 30% have > 4 comorbidities at ESRD. Many are not candidates for Transplant. Life expectancy lesser than many Cancers. Life with and with out Dialysis Same or low? European data - same Taiwan study HD inferior (EPO use registry)

16 The reason for this topic being discussed is because frail elder is different Outcome of specific treatment considered Change in Quality of life achieved Longevity due to the intervention Should we offer long term RRT in Elderly?

17 Nephrology uses intensive, expensive, and complex technologies for patient care. Dialysis programs have become efficient, fast-paced units with rapid turnover of patients. Geriatry works on simple, multidimensional, holistic, long term care to frail older patients.

18 Who is Frail and Elderly? Age is.. what you believe it is

19 FRAILITY Collective term for Sarcopenia, weakness, weight loss and functional decline. Changes in cellular level leading to alterations in homeostatic responsiveness. Individuals are at high risk for increased morbidity, hospitalisation,nursing home placement and mortality.

20 How to confirm fraility? Fried et al : presence of three of five Unintentional weight loss Self-reported exhaustion Slow gait speed Weakness (measured using a hand-grip) Low physical activity.

21 Dialysis Morbidity and Mortality Study (DMMS) Wave II study 67 % of all age group met criteria for Fraility 50 to 60 yrs age group : 66% Individuals are at high risk for increased morbidity, hospitalization,nursing home placement and mortality. Accidental fall history among the elderly

22 The incidence and progression of cognitive impairment in hemodialysis patients. J Am Soc Nephrol 17: 419A, 2006 Functional Decline,Disability and Cognitive impairment This leads to dependence. Dialysis initiation, Each hospitalisation accelerate deterioration. Dialysis cohort (n 230) during a 1-yr period 30% worsening of cognitive impairment 18% improvement over time. Silent infarcts Vs Hemodynamic instability of HD

23 Cognitive improvement Higher Hb with EPO Nocturnal dialysis

24 Survival HEMODIALYSIS, Age >75 years Canada: Average life expectancy 3.1 years ( cohort) 2.7 years ( ) UK: HD (59) Vs Non invasive care (129) 1 yr survival difference from < 15ml egfr 16 %

25 2011 JAPI, Jeloka TK et al Age >65 years, started on dialysis 2 years survival 41 % Same Hemodialysis unit, younger age group 2 year survival 96.9 %

26 CAPD More independence No other benefits proven consistently Elderly diabetics do badly on CAPD initiation

27 What do patients feel on Dialysis? 50 % Incomplete relief of Pain or distress Depression, Cognitive impairment do not change 25% want to stop dialysis 50% started as Doctor urged and regret it now 60% die in 1 year,28% decline functionally

28 End of Life discussions Scoring systems to predict life expectancy Karnofsky performance scale for function assessment Charlson comorbidity scoring system Cost of treatment and benefits No score tells you about the future of an individual patient

29 Prior continuation of care helps in making decision in an individual case. The older dialysis population has a high burden of chronic health conditions, decrements in quality of life and a high risk of death.

30 Does RRT initiation vary with physician s opinion and their experience? Is a final year PG registrar better at judging initiation of dialysis in frail elderly patient than Junior consultant (Assistant Professor) Senior consultant (Associate Professor) Professor

31 We are usually safe Financial constraints make decision easy for us. As insurance and free dialysis is catching up we shall soon face these unpleasant tasks.

32 CMC Vellore data 2017, Feb 17 to 24. weekly audit All patients with age 60yrs age on dialysis Followed up till March 29, patients 5 AKI /Acute on CKD, 2 died,3 off HD. 2 Visited for non renal Surgeries (83 year old, on HD for 6 months, LV Failure, old CVA, Myelodysplastic disease, Came for ENT surgery)

33 Age group (Yr) n=23(%) Disease n=16(%) n=12(%) n=3 (%) Total n=54 (%) Diabetes 9 (39) 13 (81) 9 (75) 1 (33) 32 (59) CAD (20) LV Failure (22) Stroke (22) COPD (7) HTN Drugs A C C E S s AVF 20 (87) 11 (69) 10 (82) 2 (67) 43 (80) AVG 1 (4) 3 (19) 1 (9) - 5 (9) Prem 2 (9) 1 (6) 1 (9) - 4 (7) Temp - 1 (6) - 1 (33) 2 (4) Death 1,LVF,COPD 1,LVF,CVA ACS Dementia 1 1shock, Fistula failed

34 Age Duration (months) Access AVF Attempts Endoluminal procedures F P DM LVF CVA F F F 1 PREMPTIVE G F F F F F F F T F 2 -

35 Expected from Nephrologist Non aggressive care TO BE EXPLAINED. More important things towards care of patient What do patient and family want? Pain relief, Treatment of depression, Stopping non essential drugs that improve taste, appetite Discuss EOL and palliative care facilities EPO

36 When decided to start on dialysis, Access Nutrition Slow initiation of dialysis Slow UF Avoid Intradialytic Hypotension. No scoring systems gives a decision on an individual patient

37 THANK YOU