clinical decisions in elderly patients with esrd
TRANSCRIPT
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Clinical Decisions in Elderly Patients with ESRD
Donna S. Hanes, M.D., F.A.C.P.Associate Professor of Medicine
Director, Internal Medicine Clerkship and Senior Rotations
Medical Director, Chestnut Dialysis Unit
ACP February 2008
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Disclosures
• No financial or other conflicts of interest
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Leonid Hurwicz, 1917
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CKD: An Epidemic
5.9
0.3
0.40.4
7.6
5.3
Stage 5Stage 5
Stage 4Stage 4
Stage 3Stage 3
Stage 2Stage 2
Stage 1Stage 1
Millions of individuals (19.2)Millions of individuals (19.2)
Coresh et al. AJKD 2003. 41; 1-12.
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US Renal Data System. US Renal Data System. 2000 Atlas of ESRD in the United States.2000 Atlas of ESRD in the United States.
00
20,00020,000
40,00040,000
60,00060,000
80,00080,000
100,000100,000
19891989 19901990 19911991 19921992 19931993 19941994 19951995 19961996 19971997 19981998
All ESRDAll ESRD
DiabetesDiabetes
HypertensionHypertension
GlomerulonephritisGlomerulonephritis
Inci
den
ce o
f N
ew P
atie
nts
Inci
den
ce o
f N
ew P
atie
nts
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CV Mortality in the General Population and in Patients with Kidney Failure
CV Mortality in the General Population and in Patients with Kidney Failure
An
nu
al M
ort
alit
y (%
)A
nn
ual
Mo
rtal
ity
(%) GP Male
GP Female
GP Black
GP White
Dialysis Male
Dialysis Female
Dialysis Black
Dialysis White
Transplant
GP Male
GP Female
GP Black
GP White
Dialysis Male
Dialysis Female
Dialysis Black
Dialysis White
Transplant
100100
1010
11
0.10.1
0.010.01
25–3425–34 35–4435–44 45–5445–54 55–6455–64 65–7465–74 75–8475–84 > 85
Age (years)Age (years)
0.0010.001
Sarnak, MJ et al. Hypertension 2003; 42: 1050-1065.
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Octogenarians and Nonagenarians Starting Dialysis
• Incident dialysis patients 13,577
• 57% increase over 6 years
• One year mortality 46%
Kurella, Ann Intern Med 2007
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Survival Rates
• Age 40 to 44• Age 60 to 64• Age over 65
• 7 to 11 years• 4 to 6 years• 5 year survival of 15%
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Guidelines for Withholding Care
• Permanently unconscious
• Severe dementia
• Severe mental disability
• Death imminent within 60 days
• End stage disease confined to bed
• Unremediable pain
• Hospitalized patients with MOF
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Withdrawal of Dialysis – Third Leading Cause of Death
• Shared decision making
• Informed consent
• Estimate prognosis
• Advanced directives
• Time limited trials
• Palliative care
RPA/ASN
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Initiation of Dialysis
• Pericarditis
• Encephalopathy
• Bleeding
• Volume overload
• Hypertensive
• Refractory metabolic disturbances
• Malnutrition
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Special Considerations in the Elderly
• 12 to 20% PCPs (and 9% nephrologists) believe there should be an age limit
• Ninety percent less likely to be offered dialysis
• Advanced Directives
• Dialysis modality
• CostTussin, AJKD 2004
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Tseng, Arch Intern Med 2008
Survival Benefit of Nephrologic Care
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Benefits of Early Referral
• Informed selection
• Timely access placement
• Non-emergent initiation of dialysis
• Lower morbidity
• Lower cost
• Improved survival
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Current Guidelines
• PTH
• Hg
• Calcium and Phosphorus
• Protein
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Complications Worsen with Complications Worsen with Progression of CKDProgression of CKD
Zabetakis et al. Am J Kidney Dis. 2000; 36(suppl 3):S31-S38.Zabetakis et al. Am J Kidney Dis. 2000; 36(suppl 3):S31-S38.
ESRDESRD
7575 5555 2525 1515 55
GFR (mL/min/1.73 mGFR (mL/min/1.73 m22))
Incr
easi
ng
Sev
erit
y In
crea
sin
g S
ever
ity
of
Co
mp
licat
ion
so
f C
om
plic
atio
ns
CKD ContinuumCKD Continuum
CKDCKDAnemiaAnemia
MalnutritionMalnutrition
Metabolic acidosisMetabolic acidosis
Secondary hyperparathyroidismSecondary hyperparathyroidism
HyperkalemiaHyperkalemia
AnemiaAnemia
MalnutritionMalnutrition
Metabolic acidosisMetabolic acidosis
Secondary hyperparathyroidismSecondary hyperparathyroidism
HyperkalemiaHyperkalemia
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Levin A; Nephro Dial Transplan 2006:21;370-377.
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Goal
Physicians should not be so preoccupied with the preservation of life that they no longer can see the
broader human context of their work: to offer some humanity at moments of suffering.
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Thank you
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Implications of doubling of serum creatinineImplications of doubling of serum creatinine
Serum Creatinine Is a Misleading Serum Creatinine Is a Misleading Guide to GFRGuide to GFR
0 1 2 3 4 5 6
25
50
75
100
125
0
Creatinineclearance
PPcrcr
Serum creatinine (mg/dL)Serum creatinine (mg/dL)
UUcrcr V V
PPcrcr