Clinical Decisions in Elderly Patients with ESRD

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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
Coresh et al. AJKD 2003. 41 1-12.
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US Renal Data System. 2000 Atlas of ESRD in the
United States.
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CV Mortality in the General Population and in
Patients with Kidney Failure
100
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GP Male GP Female GP Black GP White Dialysis
Male Dialysis Female Dialysis Black Dialysis
White Transplant
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Annual Mortality ()
0.1
0.01
0.001
2534
3544
4554
5564
6574
7584
85
Age (years)
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
• Cost

Tussin, AJKD 2004
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Survival Benefit of Nephrologic Care
Tseng, Arch Intern Med 2008
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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 Progression of CKD
CKD Continuum
ESRD
CKD
Anemia Malnutrition Metabolic acidosis Secondary
hyperparathyroidism Hyperkalemia
Increasing Severity of Complications
GFR (mL/min/1.73 m2)
Zabetakis et al. Am J Kidney Dis. 2000 36(suppl
3)S31-S38.
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Levin A Nephro Dial Transplan 200621370-377.
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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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Serum Creatinine Is a Misleading Guide to GFR
Implications of doubling of serum creatinine