Renal replacement therapy and the elderly.

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Renal replacement therapy and the elderly.

• Misha Kotlov, MD
• July 10, 2007

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Demographics.

• In the US, the primary treatment of geriatric
  ESRD patients ( 75 yrs) is in-center
  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.

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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

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Effect of Age, Gender, and Diabetes on Excess
Death in ESRD. JASN 182125-2134, 2007

• All incident dialysis patients between January
  1999-December 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.

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• Population 6 million.
• Rhône-Alpes 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.

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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
  ICD-9-CM diagnoses codes.
• Each category has an associated weight, which is
  based on the adjusted risk of one-year mortality.
  
• The overall comorbidity score reflects the
  cumulative increased likelihood of one-year
  mortality the higher the score, the more severe
  the burden of comorbidity.

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Characteristics of study population.

• Total cohort 3025 patients.
• Age 75-84 n719 85 n139
• Gender ration (m/f) 1.7
• 75 of pt 75 were treated with HD.

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SMR in ESRF versus GP of the same age and the
same gender.
9
Kaplan-Meier survival curves by age group
andstandardized mortality ratios by age group.
10
Octogenerians and nonagenarians starting dialysis
in the US.Ann Intern Med 146177-183, 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 (n350,831).
• 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 (n4,693)

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Incidence of dialysis initiation.
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Trends in dialysis initiation.

• 1996-2003, 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 80-84 yrs and
  11.9(3.2) 85 yrs.
• Annual increase in dialysis initiation among
  patients 65-79 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.

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Survival.
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Survival.

• One year mortality rate for octogenarians and
  nonagenarians starting dialysis was 46 and did
  not change over the 7-year period.
• Associated clinical characteristics
  nonambulatory status, low serum albumin
  concentration, congestive heart failure, and
  underweight were most strongly associated with
  death.

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Comparison and Survival of HD and PD in the
elderly. Seminars in Dialysis 15298-102, 2002

• Inclusion Initiated dialysis during the years
  19951997, 67 yrs at the time of initiation.
  (N89,193).
• Source Medicare claims.
• Dialytic modality Determined on day 90 of ESRD
  care, 60 days on this modality.
• After excluding all pts with missing info
  N70,208 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.

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Table 1.
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Relative risk of death.

• Death rates per 1000 patient years

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Interval death rates DM and non-DM.
19
Interval relative risks (HDPD) of death for Dm
vs non-DM.
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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.
• SF-36 physical component summary (PCS) and mental
  component summary (MCS) scores were calculated
• High scores indicate good quality of life.
• SF-36 scores were compared with UK general
  population norms for people 70 years or over and
  US norms for adults aged 6574 and 75 years or
  over.
• Lancet 2000

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Dismal rehabilitation in geriatric inner-city
hemodialysis patients.E. Freidman et al. JAMA
1994

• Cohort study of elderly patients who have
  end-stage renal disease.
• Current status was compared with patient's
  recollection of functional activity level 2 years
  before commencing maintenance hemodialysis.
• Seven outpatient, hospital-affiliated 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.

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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.

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Results.

• Karnofsky score deteriorated to average of 66
  compared with patients' recollection of a mean
  score of 84 (P 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
  
• CONCLUSIONS Maintenance hemodialysis does not
  return inner-city elderly patients to their
  predialysis level of functioning. Few elderly,
  diabetic hemodialysis patients conduct any
  substantive portion of their lives outside their
  homes.

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When to refer patients with chronic kidney
diseasefor vascular access surgery Should age
be aconsideration? KI 71555-561,2007

• Retrospective cohort study among 11,290
  non-dialysis patients with aneGFR of 25
  ml/min/1.73m2 based on 20002001 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 (n2870) of patients initiated dialysis
  within a year of cohort entry.
• Only 39 (n1104) had undergone surgery to place
  a permanent access beforehand.

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Permanent vascular access surgeries by age group.
A Percent of all cohort patients who received
pre-dialysis permanent access by the end of
follow-up. Estimates are provided with a 95
confidence interval. B Percent of patients who
initiated dialysis during follow-up that had
undergone permanent access placement before
initiation of dialysis. Estimates are provided
with a 95confidence interval.
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One year outcome by age group.
28
Ratio of unnecessary to necessary permanent
access surgeries at different theoretical
referral eGFR thresholds by age and length of
follow-up.
a Referral threshold eGFR25 b Referral
threshold eGFR20 c Referral threshold eGFR15
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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 ?