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

Disclosures

• No financial or other conflicts of interest

Leonid Hurwicz, 1917

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.

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

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.

Octogenarians and Nonagenarians Starting Dialysis

• Incident dialysis patients 13,577

• 57% increase over 6 years

• One year mortality 46%

Kurella, Ann Intern Med 2007

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%

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

Withdrawal of Dialysis – Third Leading Cause of Death

• Shared decision making

• Informed consent

• Estimate prognosis

• Advanced directives

• Time limited trials

• Palliative care

RPA/ASN

Initiation of Dialysis

• Pericarditis

• Encephalopathy

• Bleeding

• Volume overload

• Hypertensive

• Refractory metabolic disturbances

• Malnutrition

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

Tseng, Arch Intern Med 2008

Survival Benefit of Nephrologic Care

Benefits of Early Referral

• Informed selection

• Timely access placement

• Non-emergent initiation of dialysis

• Lower morbidity

• Lower cost

• Improved survival

Current Guidelines

• PTH

• Hg

• Calcium and Phosphorus

• Protein

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

Levin A; Nephro Dial Transplan 2006:21;370-377.

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.

Thank you

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