Esrd in elderly patients 2019 latest

Multidisciplinary Approach to Geriatric ESRD
Patient : Thinking Beyond Nephrology
Dr Said Khamis
MD, (MSc., KUL Belgium )
Prof. of Internal Medicine & Nephrology
Faculty of Medicine, Menoufia University, Egypt.
20-25 Oct. 2019

Geriatric Nephrology: A Growing
Challenge
Dr Said Khamis
MD, (MSc., KUL Belgium )
Prof. of Internal Medicine & Nephrology
Faculty of Medicine, Menoufia University, Egypt.
ESNT 28 Feb.2019

Agenda
• Introduction
• The Challenges of an Aging Population
• Physiologic Changes of Aging Kidneys.
• Searching for diagnostic clues
• ESRD in Elderly:
• Epidemiology & Geriatric/Internal Medicine Aspects
• A-Medical Co-Morbidities
• B-Geriatric Syndromes:
•
1-Cognitive impairment, 2-Frailty, 3-Falls.
• Nephrology Aspects
• Hemodialysis (Vasc. Access, Resources & Complications) Peritoneal Dialysis PD or HD ??
• Dialysis or Conservative? Transplantation or not? Palliative Care is anoption
• Bioethicist Perspective:
1. Patient
2. Caregiver/Family
3. Advance Care Planning
• Conclusion.

It is a fact of life—we are getting older.
The projected numbers of elderly (>65 ys.) over the
next few decades is potentially overwhelming for the
health care system.
Introduction-1
Aucella F. et al., Journal of Nephrology. Published on line 18 Jan 2019
The incidence & prevalence of kidney disease ↑ with
advancing age,

Introduction-2
The challenges facing nephrologists in dealing with
elderly patients comprises many issues
controversies in the diagnosis
 treatment of specific disease entities
 the ↑ number of complicating comorbidities
Thus, nephrologists in many parts of the world will
face epidemiologic, research, & clinical challenges.
Rosner et al.,Clin J Am Soc Nephrol 5: 936–942, 2010

Key facts (The Challenges of an Aging Population)
•Between 2015 & 2050, the proportion of the world's population over 60 years will nearly
double from 12% to 22%.
•By 2020, the number of people aged 60 years & older will outnumber children younger than
5 years.
•In 2050, 80% of older people will be living in low- and middle-income countries.
•The pace of population ageing is much faster than in the past.
•All countries face major challenges to ensure that their health and social systems are ready
to make the most of this demographic shift.
5 February 2018

The Challenges of an Aging Population
 Although the total U.S. population increased 3-fold during the
20th century, the elderly population ↑ > 10-fold.
Current Population Reports. U.S. Census Bureau. Available online at http://www.census.gov/prod/1/pop/p25- 952.pdf. Accessed January 29, 2010.
2008 National Population Projections. U.S. Census Bureau, 2008. Available online http://www.census.gov/population/www/projections/
Rosner et al.,Clin J Am Soc Nephrol 5: 936–942, 2010


In most of the world, longevity continues to increase. Life expectancy is
globally estimated at 67.2 years, (averaging 76.5 ys. in developed countries
& 65.4 ys. in developing countries).
Note: GDP, gross domestic product; m, male; f, female; PPP, purchasing power parity.
WHO statistics for Egypt as of 2016

Why is there a need for a focus on geriatric nephrology?
 Certainly, the epidemiologic facts described above substantiate
that the patient population cared for by nephrologists is elderly.
 But what issues in nephrology are specifically affected by age,
& how does age affect Dx. & Rx. in important ways?

Nephrology patient is the most complex one
compared to other medical subspecialties
Geriatric patient frequently have multiple
comorbidities
+
=
Geriatric Nephrology patient is considered a great
challenge to nephrologist

Nephrologist Evaluates etiology of CKD and determines the care plan
Advanced practitioner Educates about CKD and kidney failure treatment options
Coordinates care with family and members of the IDC team
Dietitian Dietary counseling and fluid management
Pharmacist Reviews medications, dosing, and adherence
Educates patients about the use of over the counter medications and
herbal preparations
Geriatrician/palliative care Addresses geriatric and palliative care needs
Discusses prognosis and ensures treatment plans align with goal of care
Case management/social work Assists patients to obtain needed resources (e.g., transportation and
issues with housing)
Transplant team Educates patients about transplant options
Evaluates potential transplant candidates with progressive CKD
Vascular surgery/general surgery Places and monitors access for dialysis (HD and peritoneal dialysis)
Interventional radiology Intervenes on immature or nonfunctioning AVG/AVF to improve access
flow in order to initiate dialysis
Potential roles for an interdisciplinary care clinic in CKD

Domains of interdisciplinary chronic kidney disease care
Johns T.S. , BMC Nephrology volume 16, Article number: 161 (2015)

Anatomic & physiologic changes of Aging Kidneys
 Anatomic and physiologic changes occur in the kidneys, leading to a decline in renal function of 0.75
mL/min per year, even in the absence of relevant comorbidities (i.e., HTN & DM).
 Anatomic changes include Atrophy of cortex Relative sparing of the medulla
 Kidney weight ↓ after 4thdecade
• At Birth: 50 g → 4th Decade: 400 g → 9th Decade: 300 g
• Granular surface Fibrosis& Contraction Similar to hypertensive changes
 Common physiologic changes include a ↓ blood flow, (GFR), and diluting & concentrating capacity.
 These changes can contribute to ESRD + changes in the other organ systems can significantly impact
the ability of elders to tolerate dialysis. → in significant hemodynamic alterations during dialysis → either
intolerance or inefficient dialysis. This can influence mortality, morbidity, & functional status.
.
Karam, Z et al., Clin. Geriatr. Med. 2013, 29, 555–564.
De Nicola, L.; et al., Kidney Int. 2012, 82, 482–488.

Renal ageing vs progressive nephropathy
 Aging may variably affect structures & regulatory functions of
the kidney, →↑ the propensity to develop (AKI) & progressive
(CKD).
 Very gradual changes observed in the aging kidney are clearly
different from those observed in CKD.
 Mechanisms of progressive genetic, immune, or toxic injury
are involved.

Mechanisms of
progressive aging kidney Sir William Osler, M.D 1849 -1919

What Causes The Changes?
• Franz Volhard (clinician (& Theodor Fahr (pathologist(
 Collaborators & rivals >>>>> Chicken or the Egg Controversy?
• Volhard argued that HTN → fibrosis….Fahr argued that fibrosis & inflam. → HTN
• Both were probably right.
← RAAS – NO – Klotho – Metaloprteases
Zhou, et al. K.I. (2008) 74, 710–720

Glomerular Filtration Rate
 After age 40, GFR ↓by (0.8-1) mL/min/year on average
 Renal plasma flow ↓ by 10% per decade
• Baltimore Longitudinal Study ofAging
• 254 normal subjects followed 23 years
• Mean decline of CrCl: 0.75 mL/min/year
• But 36% showed no decline
• Controversy: Simple aging or pathology?
Weinstein, JR. Adv Chronic Kidney Dis. (2010) 17: 302-307
Not Everyone Declines

Searching for diagnostic clues
 Based on the age-related yearly risk of new onset CKD, a
yearly check seems recommendable.
 The screening of renal function includes the measurement of
eGFR & albuminuria.
 KDIGO still recommend the CKD-EPI eq. to estimate GFR.
 There is however an ongoing debate in the literature regarding
the potential superiority of other equations
Schaeffner et al (2012) . Ann Intern Med 157(7):471–481.
Pottel H, et al (2016). Nephrol Dial Transpl 31(5):798–806.
Bjork Jet al (2018) Nephrol Dial Transpl 33(8):1380–1388.
Losito Aet al (2017). J Nephrol 30(1):81–86.

GFR Estimation Equations
 Based on Creatinine
• Elderly often have lower muscle mass & lower meat intake→ ↓cr.
levels
• None of the equations have been rigorously
validated for those > 70
• CG: tends to underestimate GFR in elderly
• MDRD: tends to overestimate
• Some studies show 60% discordance!
Bjork Jet al (2018) Nephrol Dial Transpl 33(8):1380–1388.
Losito Aet al (2017). J Nephrol 30(1):81–86
• BIS-1 & BIS-2 were designed for populations
>70
• BIS-1 uses Cr & BIS-2 used Cr & Cys. (median age 82),
• BIS-1, BIS-2, & CKD-EPI Cr-Cys were most accurate
Guan. Urol Nephrol (2016). doi:10.1007/s11255-016-1359-z
Willems. BMC Geriatr. 2013; 13: 113.

ESRD in Elderly
• Frequent co-morbidities: CVD, malnutrition
• Disabilities: physical, cognitive, hearing, visual
• Nursing home care (Western)
• Higher mortality: mean survival for pts. older than 75 years on RRT is 31 months
Predictors of Poor Prognosis for ESRD pts.
• Age
• Functional ability
• Nutritional status
• Comorbid illnesses (e.g. DM, MI, CHF & frailty)
 At the present time, the prevalence per million of ESRD is highest among individuals aged
65–74 years & the incidence rate is the highest among those > 75 years.
• USRDS Annual Data Report, 2017.

Growth over time of elderly treated ESKD pts..
There is a concurrent epidemic of type 2 DM worldwide
 → a marked ↑ in the number of elderly suffering DKD
 (1/3 of new ESKD >75 ys. of age are due to DKD).
U.S. Renal Data System: 2009 Annual Data Report.
Guillon CM, et al., Am J Kidney Dis 48: 212–220, 2006
O’Hare AM, et al.,J Am Soc Nephrol 18: 2758–2765, 2007

Growth over time of elderly (age >65 years) treated ESKD pts..
Mitchell Rosner et al. CJASN 2010;5:936-942
©2010 by American Society of Nephrology
Compared with 1994, the overall incidence for ESKD in the elderly in 2004 ↑ 24% for those
aged 65 to 74 years & 67% for those 75 years & older according to USRDS 2010 data show the
rapid ↑↑ in the incidence & prevalence of treated ESKD pts. over the past few decades.

0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
2 Year 5 Year 10 Year
Cancer
ESRD
Moss, A. January 20, 2010. Available at: http://www.kidneyeol.org/Moss_1-20-10.pdf. Accessed September 10, 2010.
Survival rates are lower for ESRD than for cancer pts..
Conclusions (Naylor KL.,et al., AJKD Vol XX | Iss XX | Month 2019 In Press)
Survival in incident dialysis pts. was lower than in pts. with several different solid-organ cancers.
These results highlight the need to develop interventions to improve survival on dialysis Rx. & can
be used to aid advance care planning for elderly pts. beginning treatment with maintenance dialysis

Nephrology Aspects
• Renal Replacement Therapies: Dialysis: HD, Peritoneal Dialysis; Incremental Dialysis, Kidney Transplantation
• HD (HD) versus PD(PD): Mixed results regarding mortality between HD and PD
• Kidney Transplantation: Organ allocation dilemma/ethical considerations
Geriatric/Internal Medicine Aspects
• Medical Co-morbities (Different tools and scoring systems for prognostication): Modified Charlson Score, Cohen Prognostic Model, Couchoud et al. clinical score, DOPPS, VES-13
• Geriatric Syndromes: Cognitive impairment, Falls, Dizziness, Incontinence, Depression, Frailty.
• Impact of Dialysis on Geriatric Syndromes: Worsening of symptomatology, falls, cognitive function, frailty, depression
• Physiological Changes with Aging: Functional decline in kidney function, Organ systems ageing (cardiovascular, neurologic) with more hemodynamic alterations
Bioethicist Aspects
• Patient factors: Personal values/beliefs, Disease perception, Social support/interpersonal relationships, Autonomy, Expected suffering/difficulties and death, Informed prognosis and outcomes
• Caregiver/family factors: Burden consideration—emotional, psychosocial, financial, quality of life; Support system
Palliative Care Aspects
• Conservative Management: Symptom management, Time spent at home Incremental Dialysis
• Time Limited Trial of Dialysis: Set outcomes at intervals
Ahmed F Z & Catic A G .,J. Clin. Med. 2019, 8, 5.
Multidisciplinary Approach to Geriatric ESRD Patients.

Geriatric/Internal Medicine Aspects
A-Medical Co-Morbidities
B-Geriatric Syndromes:
1-Cognitive impairment,
2-Frailty,
3-Falls.

Medical Co-Morbidities
 Many older adults suffer from multiple chronic conditions, with 68.4% of Medicare beneficiaries
having ≥2 and 36.4% having ≥4 . In addition to ESRD, common chronic diseases in the geriatric
population include COPD, CAD, & DM. The presence of comorbid chronic disease can significantly
impact dialysis outcomes.
 There are several decision tools which can assist providers in predicting prognosis and thus inform
decisions regarding the treatment of ESRD:
•1-nCI (new comorbidity index). 2-The modified Charlson (MCS) score,.
•3-Couchoud score. 4-Thamer score for older adults (≥67 years) with ESRD.
Liu, J.; et al., . Kidney Int. 2010, 77, 141–151.
Kan,et al., PLoS ONE 2013, 8, e68748.
Hemmelgarn, B.R.; et al., Am. J. Kidney Dis. 2003, 42, 125–132.
Beddhu, S.; et al., Am. J. Med. 2000, 108, 609–613.
Fried, L.;. et al., Am. J. Kidney Dis. 2001, 37, 337–342.
Couchoud, C.; et al., Nephrol. Dial. Transplant. 2009, 24, 1553–1561.
Thamer, M.; et al., Am. J. Kidney Dis. 2015, 66, 1024–1032.

Previous reports of prediction models for dialysis patients.
Inaguma D, Morii D, Kabata D, Yoshida H, Tanaka A, et al. (2019) Prediction model for cardiovascular events or all-cause mortality
in incident dialysis patients. PLOS ONE 14(8): e0221352. https://doi.org/10.1371/journal.pone.0221352
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221352

Geriatric Syndromes
(Cognitive impairment, Frailty, Falls……etc.)
 Geriatric syndromes, often defined as a multifactorial condition involving the interaction between
identifiable stressors & age-related factors, often involve multiple organ systems & can lead to significant
disability.
 Common geriatric syndromes include cognitive impairment, urinary incontinence, falls, and frailty.
 Given that geriatric syndromes generally have a significant impact on the quality of life of the elder, as
well as their caregivers, a consideration of their goals and the development of an individualized
management plan is paramount in the management of geriatric syndromes and concurrent renal
dysfunction.
 A comprehensive geriatric assessment can be very helpful in identifying geriatric syndromes,
considering the implication these will have on ESRD and possible treatment options, & predicting and
planning for issues which may arise in the future.

Cognitive Impairment
Although cognitive impairment is common in older adult patients with CKD, it is often
poorly recognized and under diagnosed. Studies have demonstrated that HD can lead
to increasing cognitive dysfunction, involving difficulty with decision-making and self-
care, including medical self-management (i.e., following medication and dietary
instructions).
Screening elders with ESRD for cognitive issues, using a standardized evaluation such
as the Montreal Cognitive Assessment (MoCA), can help inform treatment decisions,
including increasing support at home & referring to geriatric medicine if warranted.
Kurella Tamura, Met al., Clin. J. Am. Soc. Nephrol. 2010, 5, 1429–1438.

Falls
 Unintentional falls are the leading causes of nonfatal injuries among elders ≥65 years, with >3 million
occurring in 2016 according to the National Center for Injury Prevention and Control → 29,668 deaths in
geriatric individuals.
 Falls in older adults are most often multifactorial in nature, with risk factors including: visual deficits,
orthostasis, gait instability, & medication side effects.
 The risk for falls & fall-related consequences is higher in HD patients, secondary to additional
predisposing factors, including dialysis-related hemodynamic, clinical, and functional changes; ↑ rates of
polypharmacy; & a high prevalence of comorbidities, including DM, CVD, & neuropathy.
 The incidence of hip fracture among dialysis patients is four times > age-matched cohorts. The ↑
incidence of falls & fall-related injuries is an important risk factor for poor quality of life & dependency.
Cook, W.L.; et al., Clin. J. Am. Soc. Nephrol. 2006, 1, 1197–1204.

Frailty
Frailty, a common issue in older adults with ESRD, is commonly defined as a
physiologic state of ↑ vulnerability to stressors due to a ↓ physiologic reserve.
Studies evaluating frailty in individuals with CKD have determined that the prevalence
↑ as the (GFR) ↓.
 2/3 of incident dialysis patients qualified as frail.
The presence of frailty in incident dialysis patients is associated with an ↑ risk of death.
There is no data to suggest that frailty improves when dialysis is instituted.
So it is important for clinicians to evaluate elders with CKD for frailty & support them in
making an informed decision about which treatments they would wish to pursue if their
condition progresses to ESRD.

• Frailty can be defined as:
A biologic syndrome of decreased reserve
& resistance to stressors that results
from cumulative declines across multiple
physiologic systems &causes vulnerability
to adverse outcomes.
Cook WL, Jassal SV: Kidney Int 73: 1289–1295, 2008.
Diagnostic Criteria for Frailty by Fried et al. (a)
& Society on Cachexia & Wasting Disorders (b).
In both guidelines, frailty is deﬁned as the presence
of at least 3 of 5 criteria, with sarcopenia
(atrophy of skeletal muscles) as the basis.
Sameshima N, et al.,. Anti. Aging. Med. (2017) 13:52–60.

Management of ESRD in Elderly patient
• Nephrology Aspects
• Hemodialysis (Vasc. Access, Resources & Complications)
• Peritoneal Dialysis PD or HD ??
• Dialysis or Conservative? Transplantation or not?
• Palliative Care is an option.

Complex decision planning process for elderly patients with
ESRD
Vachharajani, T. J. et al. (2013) Elderly patients with CKD—dilemmas in dialysis
therapy and vascular access
Nat. Rev. Nephrol. doi:10.1038/nrneph.2013.256

Renal Replacement in the Elderly (HD)
 When considering possible RRT in geriatric patients, providers should consider the
pros/cons of each treatment modality & the impact these may have on the elder’s
overall health.
 Consulting with a nephrologist & geriatrician can be valuable in clarifying these
issues.
 Considerations with HD include:
1- the choice of vascular access,
2- resources associated with the therapy,
3- associated complications.

Hemodialysis (Vascular access)
 When considering vascular access options, clinicians should take into account the
life expectancy of the patient.
 While (AVFs) are generally preferred to (AVGs) given the lower infection risk &
relative ease of maintaining patency, they take longer to mature and there is an ↑
risk of non-maturation with increasing age
 AVGs may be a more reasonable access option in frail elders with limited life
expectancy, although should be reviewed based on an individual patient’s co-
morbidities because of their higher infection rates & an↑ in the cardiac overload.

Permanent vascular access planning in ESRD:
Factors to consider in the elderly
• Predicted life expectancy
• Degree of independence in activities of daily living
• Probability of successful access maturation • Vascular biology
• Potential for complications • Need for interventions
• Avoidance or limitation of the use of a CVC for HD
• The opinions of the patient's family and friend
• The potential impact of access choice on the QoL of the patient's main caregivers
Vachharajani T.J. et al, Nature Reviews Nephrology volume10, pages116–122 (2014)

Considerations for achieving the right vascular access at the right time for the right patient.
Karen Woo, and Charmaine E. Lok., CJASN 2016;11:1487-1494©2016 by American Society of Nephrology

MacRae et al., Canadian Journal of Kidney Health and Disease Volume 3: 1 –13. 2016
Dialysis Vascular Access :Role of Multidisciplinary Team Members

Hemodialysis (Resources & Complications)
 Resources required for HD should also assessed when considering this treatment in
elders.
 Many geriatric patients & their families find the regular travel & significant time
commitment associated with HD to be overly burdensome.
 Finally, elders receiving HD are at an ↑ risk of complications, including hemodynamic
instability, depression, cognitive decline, malnutrition, and infections.

Hemodialysis (An incremental dialysis approach?? -1)
Clinical practice guidelines recommend against prescribing less than thrice-weekly
dialysis for patients without substantial residual renal function.
There have been no randomized controlled trials that studied dialysis dose in patients
with substantial RRF.
 RRF has been shown to improve overall health & well-being and its decline has been
shown to be a strong predictor of mortality.
The concept of incremental dialysis has been emerging, which offers opportunity to
expand dialysis frequency & individualize dialysis therapy.
Kalantar-Zadeh, K. et al., Semin. Dial. 2017, 30, 251–261.
Piccoli, G.B et al., J. Clin. Med. 2018, 7, 331

Hemodialysis (An incremental dialysis approach??- 2 )
Among incident HD patients with substantial RRF, incremental dialysis may be a better
option to preserve renal function & a better health-related QoL, which are among the
strongest predictors of survival in the 1st year of dialysis.
In older adults, an incremental dialysis approach starting with one to two dialysis
sessions per week can help them adapt to the dialysis.
Dialysis prescription can vary in each individual patient based on multiple co-
morbidities, tolerance, & other factors.
 A personalized approach to dialysis prescription, as proposed by Piccoli et al., can
help achieve a more patient-centered approach in older adults initiating dialysis.
Kalantar-Zadeh, K. et al., Semin. Dial. 2017, 30, 251–261.
Piccoli, G.B et al., J. Clin. Med. 2018, 7, 331

Peritoneal Dialysis
 When considering PD in elders, barriers to participation and relative contraindicates must be
considered. Compared to HD, PD requires significant technical participation from the patient or
caregiver.
 Elders with significant impairment of cognition, vision, or dexterity would be poor candidates for PD
unless a caregiver could provide significant assistance with the process.
 However, if elders are able to participate in PD independently or with assistance, they may prefer this
method as it does not require them to leave their home.
 Medical conditions which are a relative contraindication to PD include severe pulmonary disease;
significant scarring from previous abdominal surgery; uncorrectable hernias; active inflammatory bowel
disease; and colostomy, ileostomy, or gastric tubes.
Oliver, M.J.; & Quinn, R.R. Perit. Dial. Int. 2015, 35, 618–621.

HD or PD?
The results of studies comparing mortality between HD and PD in older adults have
been mixed
Studies have found increased mortality among diabetic patients receiving PD
compared to HD.
A meta-analysis done in Korean patients by Han et al. showed a higher death rate in
elderly PD patients than those on HD .
There was no difference in the quality of life and physical function between PD & HD
patients in the age group of 60 plus.
Winkelmayer, W.C.; et al., JASN. . 2002, 13, 2353–2362.
Han, S.S.; et al., . JASN. . 2015, 10, 983–993.
Iyasere, O.U., et al., JASN. 2016, 11, 423–430.

Marcia Regina Gianotti Franco & Natália Maria da Silva Fernandes., J Bras Nefrol 2012;34(3):132-141

Dialysis or not?
Importantly, non-dialysis care does not mean
imminent death. (very slow deterioration in eGFR)
Dialysis ↑ life span, provides symptom relief,
improves QoL, & can help fulfill personal wishes.
 Dialysis also comes with complications
Age by itself is not a contra-indication for dialysis.
A multidisciplinary approach is needed in dialysis
decision-making in geriatric ESRD population.
Faheemuddin Azher Ahmed & Angela Georgia Catic., J. Clin. Med. 2019, 8, 5;

A comparative survival study of pts. over 75
years with chronic kidney disease stage 5
Retrospective analysis of 129 pts. , Follow-up ~570 days
Murtagh et al, Nephrology, Dialysis Transplantation 2007
Dialysis or Conservative?

Conservative Management/Patient-Centered Palliative Care
While there is generally a survival benefit for dialysis patients when compared to
patients with ESRD who receive conservative Mx, this is often at the expense of
patient goals, values, & lifestyle.
Patients on dialysis spend a significant amount of time interacting with the medical
system (i.e., dialysis, hospitalizations), which can result in physical & psychosocial
stressors leading to a lower quality of life & ↑ risk of dying in the hospital.
A patient-centered, palliative care approach should be offered to patients with ESRD,
with the goal of providing care which aligns with the patient’s goals & values.
Carson, R.C. et al .; Clin. J. Am. Soc. Nephrol. 2009, 4, 1611–1619.
Davison, S.N et al .; Clin. J. Am. Soc. Nephrol. 2016, 11, 1882–1891.
Scherer, J.S et al .; Clin. J. Am. Soc. Nephrol. 2016, 11, 344–353.

Conservative Management/Patient-Centered Palliative Care
Palliative dialysis is aimed at improving quality of life by treating symptoms & distress.
It may involve modification of duration and/or frequency of dialysis sessions.
 Symptom management is aimed at ameliorating symptoms associated with CKD.
There may be scenarios which are confounded by prognostic uncertainties & a lack
of clear goals from the patient & /or family. In these scenarios, a time-limited trial of
dialysis may be indicated.
 This will help patients, families/caregivers, & providers to evaluate the response to
RRT & decide on future treatments which best support the goals of care.
Carson, R.C. et al .; Clin. J. Am. Soc. Nephrol. 2009, 4, 1611–1619.
Davison, S.N et al .; Clin. J. Am. Soc. Nephrol. 2016, 11, 1882–1891.
Scherer, J.S et al .; Clin. J. Am. Soc. Nephrol. 2016, 11, 344–353.

Key components of the Conservative Kidney Management Pathway.
Sara N. Davison et al. CJASN 2019;14:626-634

Clinical condition is incorporated into the conservative kidney management recommendations.
Sara N. Davison et al. CJASN 2019;14:626-634

Role of supportive care in advanced
CKD management
Aggressive treatment Bereave-
ment
Supportive
care
Pain control Symptom control Psycho-social support
Awareness of patient goals & concerns
Time
Dialysis Transplant Access Surgery Antibiotics

Palliative Care is an option
 Take into account functional status & comorbidities.
• For those who choose dialysis vs. conservative Mx ,
average survival is 8.3 vs. 6.3 months.
• But more hospitalizations, more transport to & from the
HD center.
 Health system is poorly setup for palliative care in ESRD
• Conservative Mx. needs More work; frequent clinic visits….
Da Silva-Gane Clin J Am Soc Nephrol. 2012 Dec 7; 7(12): 2002

When is Palliative Care Needed?
Around the decision to stop dialysis
At the onset of conservative management
When symptoms from co-morbid conditions are severe
At times of crisis e.g. new diagnosis of malignancy, or acute
severe symptoms
Pts. who develop renal failure as a consequence of other
life threatening conditions or its treatment e.g. cancer

While performed less frequently than dialysis in the geriatric population,
has been shown to increase life expectancy and improve quality of life
compared to dialysis.
Determining who would derive the greatest benefit from transplants given
the shortage of donor organs will continue to be an important ethical
consideration as increasing numbers of individuals survive into advanced
old age with ESRD.
Huang., et al., Semin. Nephrol. 2009, 29, 621–635.
Wolfe, et al., N. Engl. J. Med. 1999, 341, 1725–1730.
Rao, et al., Transplantation 2007, 83, 1069–1074.
Kidney transplantation
In a study by Wolfe et al. comparing mortality in wait-listed dialysis
patients versus recipients of a first cadaveric transplant, the transplant
recipients demonstrated improved longevity at all ages, including
patients who were 60 to 74 years of age. Transplantation100(10):e55-e65, October 2016

(Transplantation 2016;100: e55–e65)

CONCLUSIONS & RECOMMENDATIONS (RT):
1. RT was shown to be superior to dialysis in terms of pt.
survival &, QOL & cost-effectiveness.
2. Graft survival is similar or even better in elderly RT
recipients, as compared with younger counterparts.
3. RT appears to be safe in the elderly, if candidates are
carefully selected.
4. All guidelines recommend that pts. should not be
deemed ineligible for RT based on age alone.
(Transplantation 2016;100: e55–e65)

Bioethicist Perspective
1. Patient
 Patients base their decisions on multiple factors, including personal values, beliefs, disease perception,
social support, interpersonal relationships, autonomy, expected suffering, informed prognosis, and
outcomes .
 Although disease course and complications in CKD differ from cancer & other terminal illnesses, patient
preferences & end-of-life discussions should be carried out in a similar manner, with a special focus on
the disease/symptom trajectory.
 In a study by Davison, around 90% of the patients reported that their nephrologist did not discuss the
prognosis with them. & around 60% of the cases, the choice to pursue dialysis was either their
physician or family’s wish. The study also found that the majority of dialysis patients regretted their
dialysis decision.
 A patient-centered treatment plan should be outlined and aligned with the patient’s goals & values in
conjunction with prognostication information.
Ahmed A Z et al.,J. Clin. Med. 2019, 8, 5
 Holly and Schell’s review article provides a decision-making guide for
nephrologists, including different questions to address while exploring
goals for patients. It also guides in preparing patients and families at
different stages of the disease process.

2. Caregiver/Family
The elderly ESRD patients, may require even more assistance once dialysis is added
to their treatment plan.
 The burden & adverse effects on the family &/or caregivers is not just limited to
physical impacts, but also may affect emotional, psychosocial, financial, & quality of
life arenas.
Caregivers should be educated about the different aspects/activities involved in
dialysis.
A social support system should be established.
 Caregivers should also be monitored periodically for any impact in their physical,
functional, and mental quality of life. Belasco, A. et al;. Am. J. Kidney Dis. 2006, 48, 955–963.
Alvarez-Ude, F.et al; J. Nephrol. 2004, 17, 841–850.

3. Advance Care Planning
 Clinical practice guidelines have recommended advance care planning (ACP) in
dialysis patients.
 Nephrologists should lead the discussions in ACP.
 The documents that are involved in advance care planning are known as advance
directives and include Living Will (LW), Durable Power of Attorney for Health Care
(DPAHC), and Physician Orders Life Sustaining Treatment (POLST).
 This can help the decision-making process at the end of life in ESRD patients,
especially withdrawal from dialysis.
Shared decision-making in the appropriate initiation of and withdrawal from dialysis. In Clinical Practice
Guideline, 2nd ed.; Renal Physicians Association: Rockville, MD, USA, 2010.

 Certainly, the epidemiologic facts substantiate that the patient
population cared for by nephrologists is elderly.
A dramatic ↑ in prevalence of CKD with ageing
Early recognition & interventions is very crucial.
Nephrologists & geriatricians are more & more involved in
Dx & caring older pts. with CKD.
Conclusion-1

Conclusion-2
The complexity characterizing the elderly patient
could mask kidney disease
Renal diseases are a major problem in the elderly,
but also a treatable & somewhat, preventable one
Involving PCP may help to obtain early
identification & correct referral of older CKD pts.

Conclusion-3
A nihilistic attitude would carry the risk of leaving a treatable condition
untreated.
On the other hand, a too aggressive & untailored approach might be harmful.
Age by itself is not a contra-indication for dialysis. However, when coupled
with multiple co-morbidities, geriatric syndromes, and functional impairment,
it may not be the best treatment decision for all patients.
 Thus, a renewed Dx & Rx process is expected to stem from a positive &
reciprocal collaboration of the nephrological & geriatric cultures.

Nobel Prize: 97-year-old chemist John Goodenough becomes oldest-ever winner

The End of Life must be like this Beautiful Sunset
Forever Young

Julien Al Shakarchi published a systematic review and meta-analysis that looked at 19 studies involving different
ECGs including Flixene, Avflo, Acuseal and Vectra grafts. Primary patency rates ranged from 40-60% and secondary
patency ranged from 70-85%. This systematic review suggests that the patency of the early cannulation graft is
comparable to the conventional ePTFE AVG, though long term data is lacking T Patency rate comparison for the
different types of ECGs is not available as there have been no head-to-head trials..
 primary patency (intervention-free access survival) refers to interval from time of access placement to any
intervention designed to maintain or reestablish patency or to access thrombosis.
 Secondary patency or access cumulative patency refers to interval from time of access placement to access
abandonment, including intervening manipulations (surgical or endovascular interventions) designed to reestablish
the functionality of thrombosed access)
https://www.ncbi.nlm.nih.gov/pubmed/294870923.
Early Cannulation Arteriovenous Graft (ECG).

In a study that performed a cost analysis of HeRO grafts, a cohort of 100 patients, patients with a HeRO graft had
6 fewer access-related complications,53 fewer access-related infections and 67 fewer device thrombosis as
compared to patients with TDC’s.

Key points (vascular access )
• Management of chronic kidney disease in elderly patients is complex
• Planning for renal replacement therapy and dialysis vascular access
requires evaluation of comorbidities and quality of life
• Selection of the ideal vascular access for an elderly patient requires pre-
operative vessel mapping and consideration of vascular biology, the
patient's ability to function independently and their anticipated life
expectancy
• Ethical issues, optimal timing of vascular access creation and predicting the
outcomes of various types of permanent access remain challenging

Generalevaluationofkidneytransplantcandidates
...
Transplantation100(10):e55-e65,October2016

1.For selected elderly ESRD patients, RT was shown to be superior to dialysis in terms of patient survival and, possibly, QOL and cost-effectiveness.
2.Death-censored graft survival is similar or even better in elderly RT recipients, as compared with younger counterparts.
3.RT appears to be safe in the elderly, if candidates are carefully selected. Given the senescence of the immune system, the use of lower doses of
immunosuppressive drugs is likely to minimize side effects, without excess rejections; however, specific options need to be tested in randomized
controlled trials.
4.Virtually all guidelines recommend that patients should not be deemed ineligible for RT based on age alone.
5.A short life expectancy generally precludes RT; however, this principle may be difficult to interpret and apply in clinical practice, because there is no
general consensus over the definition of ―short,‖ and it is often unclear how life expectancy can be estimated.
6.The evaluation of elderly patients for RT basically has the same objectives and uses the same methods as for all RT candidates. This involves
thorough medical and psychosocial assessment. However, the existing guidelines contain very few specific recommendations on the criteria to use for
selecting elderly candidates for RT.
7.Many guidelines recommend that elderly potential candidates for RT should be screened more aggressively and more frequently for cardiovascular
disease and cancer. Significant age-related comorbidities could be considered as relative contraindications to RT. However, the specific investigation
methods and time intervals to be used, as well as criteria for exclusion, are still poorly defined and not supported by evidence.
8.For cardiac evaluation, noninvasive stress testing may be considered in asymptomatic patients 60 years or older who also have at least 2 other risk
factors for coronary artery disease, although there is little evidence to support this recommendation.
9.With regard to malignancy, age-appropriate screening as indicated for the general population should be performed for RT candidates, in the absence
of specific guidelines for these patients. This usually includes colonoscopy in patients 50 years or older and mammogram in women 40 years or older.
10.Several comorbidity scores can predict post-RT mortality and might be used to guide decision-making on eligibility. However, such scores should be
validated in additional studies.
11.The assessment of frailty might also play a role in the selection of elderly patients for RT. Various scales have been proposed in this regard.
However, there is still very limited information about the impact of frailty on mortality in elderly RT recipients, and there are no guidelines indicating at
which level of frailty (if any) a patient should be excluded from a waiting list. (Transplantation 2016;100: e55–e65)
12.Psychosocial issues, including cognitive deterioration, depression, social isolation, and financial problems, are common in elderly patients and may
have a significant impact on compliance to prescriptions and, ultimately, on patient and graft outcomes. Therefore, these issues should be assessed
prior to RT wait listing, as well as thereafter. Specific questionnaires can be used to identify patients who are more likely to be non adherent.
13.Elderly patients should be encouraged to consider ECD and LD, as alternatives to deceased SCD, in order to increase their chances of access to
RT. It has been demonstrated that ECD RT in patients 60 years or older is associated with higher survival rates than remaining on dialysis, while LD
RT is superior to all other options. Systems like the ESP—which offers preferential allocation of ECDs to this age group—should be promoted.

Two phenotypic frailty scales5
Transplantation100(10):e55-e65, October 2016

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