Geriatric Nephrology. Murtener Tage

Transcription

1 Geriatric Nephrology Murtener Tage

2 Plan Geriatric nephrology The elderly with CKD The elderly on dialysis The elderly in transplantation

3 Plan Geriatric nephrology The elderly with CKD The elderly on dialysis The elderly in transplantation

4 «geriatric nephrology»

5 From the pyramid to the bottle to the bell

6 The coming age of geriatric nephrology?

7 Geriatric nephrology Geriatric nephrology is the branch of internal medicine and geriatric medicine that deals with diseases of the kidney It is a growing subspecialty of geriatrics. Patients who are living longer may acquire diseases that accelerate chronic kidney disease, which often remains undetected until patients are confronted with the sudden need for dialysis.

8 What is the background of Age-related status Malnutrition geriatric nephrology? Cognitive impairment Physical disabilities - frailty Depression High prevalence of DM and vascular disease Need for accurate and individualised patients care QOL shared decision making Careful use of drugs risk of AKI Aim to decrease hospitalisation and morbidity Cavalli et al J Nephrol 2010

9 2013 Nitta et al. Aging and CKD Kidney Blood Press Res Morphological changes of the aging kidney

10 For 70+: GC gives lower estimation of GFR With aging muscle mass and fat tissue 2013 BMC Geriatrics

11 Rosner et al CJASN 2010 Differences between elderly and non-elderly CKD patients? The relevance of reduced egfr The use of diagnostic procedures esp. Bx The progression factors such as proteinuria The pharmacokinetics/dynamics of drugs The impact of therapeutic interventions RAAS blockade Immunosuppression

12 Plan Geriatric nephrology The elderly with CKD The elderly on dialysis The elderly in transplantation

13 Does age modify the prognosis of patients with CKD in nephrology care? Non linear relationship between age and egfr! Kidney Int 2012

14 The unfavourable effect of diabetes and cv disease decreases /disappears with older age Proteinuria increases the risk of ESRD with age but the effect diminishes from CKD3 to CKD5 De Nicola et al Kidney Int 2012

15 2013 BMC Nephrology Dialysis 11% Death 27% 155 patients referred to nephrologists >80 years old egfr <45 3 years FU

16 Plan Geriatric nephrology The elderly with CKD The elderly on dialysis The elderly in transplantation

17 CJASN 2010

18 Age repartition of dialysis patients in 2014 Survival 3.3 yrs % <65 44% Survival 5.6 yrs Survival 3.8 yrs >70 46%

19 2013 Nitta. Kidney Blood Press Res Challenges of RRT in the elderly Limitation in mobility and transportation Family support / income Cardiovascular disease burden Competing mortality risk Option of non-dialytic strategy Expectations regarding QOL

20 Sem Dial 2013 US has a seven fold higher dialysis rate in adults than UK The decline of incidence in RRT occurs 5 years later in the US Different approach regarding shared decision making and conservative care?

21 CJASN 2009 Frailty highest prevalence rate in dialysis population of 65+ Accidental falls higher rate than age-matched population Functional decline and disability starts at mild impairment of renal function, increases under dialysis Cognitive dysfunction benefits from good Hb and good dialysis Prolonged survival but how much vs good palliative care and at which QOL?

22 Kidney Int 2008 Cross-sectional study of 65+ on chronic outpatient HD 162 mostly male patients in Canada, average of 75 yrs old 5% no disability 43% instrumental dependance only 52% combined functional and instrumental disability Significant multivariate OR for dependency Education OR 0.88 ( ) Total medication OR 1.25 ( ) Poor «timed up and go» OR 6.64 ( )

23 Bonani et al SGN 2010 Score with 9 easy to access risk factors Retrospective score calculation confrontation of the score prediction with the effective outcome , 41 patients >75 starting dialysis Outcomes: Remaining on HD, withdrawing form HD, dying or recovering renal function A clinical score to predict 6 month prognosis in elderly patients starting dialysis for ESRD Couchoud C, et al. for the REIN in NDT 2009; 24:1553

24 Bonani et al SGN 2010

25 Trait et al. Sem Dial 2013 Conservative care: which are the key elements? Access to multi-skilled renal team with expertise in Communication Shared decision making Symptom management Prognostic assessment Timely information about the choices available and palliative care plan Ongoing medical treatment Dignity in death and where possible to die

26 NDT 2013

27 Van de Luijtgaarden et al. NDT 2013

28 Plan Geriatric nephrology : background The elderly with CKD The elderly on dialysis The elderly in transplantation

29 Kidney transplant in 65+ Waiting-list 03/ % >70 5% <65 80% Kidney recipients >70 3% % <65 88%

30 Cooper and Forland 2011 CO in Organ Transplantation Outcome of 65+ transplant recipients Death censored

31 Mortality Young No co major comorbidity Planned Tp with Living donor Older / elderly With DM / cv disease Non elective surgery Older deceased donor / with extended criteria Dialysis Kidney Tp 3 months for equal risk Zeit

32 Transplantation 2007

33 2011 CO in Organ Transplantation

34 The future of geriatric nephrology Develop special competences to deal with geriatrics Perform national studies to analyse the issues Resident population Psycho-social dimension Factors of CKD progression Develop and structure the management in conservative care