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Unformatted text preview: Renal replacement therapy and the elderly.
Misha Kotlov, MD July 10, 2007 Demographics.
► In the US, the primary treatment of geriatric ESRD patients (> 75 yrs) is incenter hemodialysis (96 %)
CAPD/CCPD account for approximately 3.5 %
The average age of the patient undergoing dialysis in the US has been steadily increasingly over the last several decades.
In 2000 the average age was approximately 62 yrs.
According to United States Renal Data System database, the number of patients > 80 yrs of age who initiated dialysis increased from 7054 patients in 1996 to 13,577 individuals in 2003. Issues at hand.
Issues at hand.
► Important points to consider when evaluating the treatment of elderly patients with ESRD include:
► Life expectancy of such patients ► Effect of ESRD on life expectancy and quality of life ► HD vs PD
► Timing of access placement Effect of Age, Gender, and Diabetes on Excess Effect of Age, Gender, and Diabetes on Excess Death in ESRD. JASN 18:21252134, 2007
► All incident dialysis patients between January 1999December 2003 in Rhone
Alpes region, France.
► 3025 patients were analyzed.
► Age and gender standardized mortality ratio (SMR) was computed in ESRD vs general population of the region.
► Overall and by patient subgroups. ►
► Population 6 million.
RhôneAlpes is located in the east of France. The east of the region contains the western part of the Alps. The highest peak is Mont Blanc. The central part of the region is taken up with the valley of the Rhône and the Saône. The confluence of these two rivers is at Lyon, the capital of the region. ►
► “There are three kinds of lies: lies, damned lies, and statistics.”
Benjamin Disraeli, Prime Minister of England end of 19 century.
Standardized Mortality Ratio
SMR = Observed Deaths / Expected Deaths
Excess Deaths = Observed Deaths Expected Deaths
Charlson Index contains 19 categories of comorbidity, which are primarily defined using ICD9CM diagnoses codes.
Each category has an associated weight, which is based on the adjusted risk of oneyear mortality. The overall comorbidity score reflects the cumulative increased likelihood of oneyear mortality; the higher the score, the more severe the burden of comorbidity. Characteristics of study population.
Characteristics of study population.
► Total cohort 3025 patients.
► Age 7584: n=719; >85: n=139
► Gender ration (m/f) = 1.7
► 75 % of pt >75 were treated with HD. Survivlal Total
% 7584 yrs >85 1 yr 82 69 59 2 yr 70 50 39 3 yr 62 37 23 4 yr 55 26 12 5 yr 48 18 9 SMR in ESRF versus GP of the same age and the SMR same gender. KaplanMeier survival curves by age group and
standardized mortality ratios by age group. Octogenerians and nonagenarians starting dialysis Octogenerians and nonagenarians starting dialysis in the US.
Ann Intern Med 146:177183, 2007
► USRDS Standard Analysis Files from 1996 through 2003 for these analyses.
► Included all persons 65 years of age and older who began dialysis between 1 January 1996 and 31 December 2003 (n=350,831).
► The focus of these analyses was the very elderly;
► Included patients 65 to 79 years of age (the “young” elderly) in the analyses as a reference group. ► Excluded patients initiating dialysis after a failed kidney transplantation (n=4,693) Incidence of dialysis initiation.
Incidence of dialysis initiation. Trends in dialysis initiation.
Trends in dialysis initiation.
► 19962003, 78,419 octogenarians and 5,577 nonagenarians initiated dialysis in the United States.
7,054 pts in 1996 13,577 pts in 2003: average annual increase 8.6%(2.3%) in 8084 yrs and 11.9%(3.2%) > 85 yrs.
Annual increase in dialysis initiation among patients 6579 yrs was 3.5%(0%). Accounting for population growth, rates of dialysis initiation increased by 57% among octogenarians and nonagenarians from 1996 to 2003. For persons older than 84 years of age, rates of dialysis initiation were dramatically lower than other elderly age groups; this effect persisted over time. Survival.
► ► One year mortality rate for octogenarians and nonagenarians starting dialysis was 46% and did not change over the 7year period. Age group, Associated clinical characteristics: nonambulatory status, low serum albumin concentration, congestive heart failure, and underweight were most strongly associated with death. 6579 Median survival, mo
25 Average life expectancy, mo
? 8084 15 105 8589 12 75 >90 8 57 yrs Comparison and Survival of HD and PD in the Comparison and Survival of HD and PD in the elderly. Seminars in Dialysis 15:2:98102, 2002
► ► Inclusion: Initiated dialysis during the years 1995±1997, >67 yrs at the time of initiation. (N=89,193). Source: Medicare claims. Dialytic modality: Determined on day 90 of ESRD care, >60 days on this modality.
After excluding all pts with missing info: N=70,208; 6,695 (10%) on PD and 63,513 (90%) on HD
Interval Poisson regression was used to calculate adjusted death rates and relative risks between the PD and HD populations.
Analyses were adjusted for age, gender, race , geographic location (six groups of renal networks), Charlson comorbidity index score, baseline GFR, prior hospital days, incidence year (1995, 1996, 1997), and primary cause of renal failure (diabetes, hypertension, GN, other).
Separate analyses were performed for the diabetic and nondiabetic populations. Table 1.
Table 1. Death rates per 1000 patient years Relative risk of death.
Relative risk of death. Interval death rates DM and nonDM. Interval relative risks (HD:PD) of death for Dm vs nonDM. The longer, the better?
The longer, the better?
► 12 month prospective cohort study of outcomes in 221 patients with ESRD, started on HD, age >70 yrs.
Recruted from 4 hospital based dialysis units.
Quality of life was assessed by interview at 90 days after initiation of HD in new patients and at 5 months to 10.8 yrs in chronic patients. SF36 physical component summary (PCS) and mental component summary (MCS) scores were calculated;
High scores indicate good quality of life. SF36 scores were compared with UK general population norms for people 70 years or over and US norms for adults aged 65–74 and 75 years or over. Lancet 2000 Dismal rehabilitation in geriatric innercity Dismal rehabilitation in geriatric innercity hemodialysis patients.
E. Freidman et al. JAMA 1994
► Cohort study of elderly patients who have endstage renal disease.
Current status was compared with patient's recollection of functional activity level 2 years before commencing maintenance hemodialysis. Seven outpatient, hospitalaffiliated and private hemodialysis units in Brooklyn, NY. 104 patients aged 65 years or older who were receiving maintenance hemodialysis for at least 6 months.
Measured outcome: A score of 76 or greater on a modified Karnofsky scale indicated independent function at a level that permitted participation in activities beyond those mandated by the hemodialysis regimen. Karnofsky performance scale. Karnofsky performance scale.
► 100% normal, no complaints, no signs of disease 90% capable of normal activity, few symptoms or signs of disease 80% normal activity with some difficulty, some symptoms or signs 70% caring for self, not capable of normal activity or work 60% requiring some help, can take care of most personal requirements 50% requires help often, requires frequent medical care 40% disabled, requires special care and help 30% severely disabled, hospital admission indicated but no risk of death 20% very ill, urgently requiring admission, requires supportive measures or treatment 10% moribund, rapidly progressive fatal disease processes 0% death. Results.
► ► ► Karnofsky score deteriorated to average of 66 compared with patients' recollection of a mean score of 84 (P < .001) 2 years before initiation of hemodialysis. Diabetic patients had a lower score than nondiabetic patients. Within the diabetic subset, severe debility constrained 71 patients (68%) to limit all activity to their residence with the exception of travel to and from their dialysis facility. 2 years prior to commencing dialytic therapy, 81 diabetic patients (78%) had interests and activities that took them outside their homes (P < .001). CONCLUSIONS: Maintenance hemodialysis does not return innercity elderly patients to their predialysis level of functioning. Few elderly, diabetic hemodialysis patients conduct any substantive portion of their lives outside their homes. When to refer patients with chronic kidney disease
for vascular access surgery: Should age be a
consideration? KI 71:555561,2007
► ► ►
► Retrospective cohort study among 11,290 nondialysis patients with aneGFR of 25 ml/min/1.73m2 based on 2000–2001 outpatient creatinine measurements in the Department of Veterans Affairs. For each age group, the percentage of patients that had and had not received a permanent access by 1 year after cohort entry, and the percentage in each of these groups that died, started dialysis, or survived without dialysis was established.
Modeled the number of unnecessary procedures that would have occurred in theoretical scenarios based on existing vascular access guidelines.
The mean eGFR was 17.7 ml/min/1.73m2 at cohort entry. Mean age of the patient cohort was 70 yrs.
25% (n=2870) of patients initiated dialysis within a year of cohort entry.
Only 39% (n=1104) had undergone surgery to place a permanent access beforehand. Permanent vascular access surgeries by age group.
Permanent vascular access surgeries by age group. A Percent of all cohort patients who received predialysis permanent access by the end of followup. Estimates are provided with a 95% confidence interval.
B Percent of patients who initiated dialysis during followup that had undergone permanent access placement
before initiation of dialysis. Estimates are provided with a 95%confidence interval. One year outcome by age group.
One year outcome by age group. Ratio of unnecessary to necessary permanent access surgeries at different theoretical referral eGFR thresholds by age and length of followup. a Referral threshold eGFR=25 b Referral threshold eGFR=20
c Referral threshold eGFR=15 Conclusion.
Conclusion. ► Rates of initiation of dialysis in elderly is increasing: increase ckd prevalence, earlier initiation of dialysis, more liberal acceptance in dialysis programs.
► Dialysis can significantly prolong life in elderly population.
► Elderly seem to do better on HD vs PD.
► QOL: more studies needed.
► Access: when should avf/avg be placed in elderly ? ...
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