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Management of Acute Renal Failure in the Elderly Patient

You've successfully added to your alerts. You will receive email when new content is published. Specialty: Multispecialty. Log In. Sign Up It's Free! Register Log In. No Results. If you log out, you will be required to enter your username and password the next time you visit. Log out Cancel. Aging Health. In This Article. Abstract and Introduction Abstract The global population is progressively aging, to the extent that over 1. Next Section. Sidebar Executive Summary Background The global population is progressively aging.

Pathophysiology With progressive aging, the kidney undergoes anatomical and physiological changes due to either organ senescence or other specific diseases, such as atherosclerosis or diabetes, that are highly prevalent in the elderly. Potential Risk Factors for Age-related Decline in Renal Function A range of clinical and biohumoral factors, including hypertension, hyperfiltration, metabolic syndrome and previous acute kidney injury, could potentially affect age-related decline in renal function.

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Specific Complications in Frail Elderly Patients With ESRD In elderly patients with severe multimorbidity, physicians should strive to enhance quality of life by treating multimorbidity-related symptoms and addressing common geriatric syndromes, such as depression, urinary incontinence, injurious falls and polypharmacy. Therapeutic Targets The main challenges in treating older patients with ESRD are the existence of age-specific targets for several clinical parameters, the high prevalence of comorbidities and frailty phenotype and, most importantly, the relative lack of prospective, randomized, controlled trials in such patients.

Managing End-Stage Renal Disease in the Elderly

Choosing the Most Appropriate Treatment Option in Elderly Patients With ESRD Once an elderly patient receives a diagnosis of chronic kidney disease, physicians are asked to make choices about the future management of the disease; in particular, whether dialysis treatment is the most appropriate choice. Quality of Life in RRT A patient's decision to decline or accept dialysis treatment is often based on personal considerations, beliefs and feelings toward life and death. Evidence suggests that, though serum creatinine concentration alone is insufficient to allow correct estimation of GFR in older people without some correction for creatinine generation, none of the established formulae consistently outperforms the others.

Acute Kidney Injury and AKI Biomarkers in the ICU - John Kellum, MD

Relative performance is influenced by the methodology of creatinine measurement and the case-mix of the cohort age, CKD stage and prevalence of frailty. If more exact knowledge of kidney function is sought, formal GFR measurement should be considered, though such testing may be laborious and expensive. For drugs or their active drug metabolites that are cleared by the kidneys, dosing should be adapted to renal function.

The purpose of this question is to provide guidance to clinicians on how best to estimate the risk of progression of CKD to end-stage kidney disease ESKD in older patients. We therefore need robust methods to identify those at high risk of progression so that they can be offered optimal nephroprotective therapy and timely preparation for RRT.

Preparation for RRT in older people may be protracted due to multi-morbidity and frailty. Risk prediction is challenging because GFR decline may not be linear [ 12 ] and rapid decline may occur due to relatively unpredictable episodes of acute kidney injury [ 13 ] for which older people are at greater risk.

It is also important to consider the competing risk of death in older people.

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Hence identification of the majority who are at low risk of progression could avoid the morbidity and stress associated with unnecessary interventions in preparation for RRT. Older people are often excluded from studies to evaluate nephroprotective interventions or develop risk prediction scores for CKD, so it is not clear whether scores developed in younger people will perform adequately well in older people. A correction factor may need to be applied in non-North American populations. The 8-variable score performed only marginally better than the 4-variable.

Only basic demographic and laboratory data are required for the 4-variable score, enabling a risk estimate to be generated automatically by laboratory computer systems. Frail patients should be managed as high risk 2C. Correctly identifying those people likely to die within the next few months, regardless of whether RRT is started, may avoid their being subjected to the added burden of the dialysis pathway.

On the other hand, identifying those likely to live longer may inform shared decisions, balancing quality versus quantity of life. Few available risk prediction models have targeted older people with advanced CKD. Fewer still have been tested in populations outside those used to develop them.

Hence it is unclear whether existing models reliably help estimate risk of death in older people with advanced CKD. We found that the Bansal risk prediction model had the best credentials to be recommended as a tool for predicting the absolute probability of death within 5 years for older people with CKD stage 3—5 not on dialysis [ 6 ]. The model includes nine readily available demographic, clinical and biochemical predictors: age, sex, ethnicity, eGFR, urinary albumin-to-creatinine ratio, diabetes, smoking, history of heart failure and stroke.

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Model discrimination was moderate in both development and validation cohorts c-statistic 0. External validation is lacking in cohorts including a substantial proportion of frail older patients. Since frailty is an independent risk factor for mortality [ 15 ], we hesitate to recommend the score as the sole means of predicting mortality in this population.

A high Bansal score will deliver a reliable prediction irrespective of the presence of frailty, but in those with a low score, a validated frailty score is likely to contribute useful additional information on mortality. The model included nine demographic, clinical and biochemical predictors: age, sex, history of congestive heart failure, peripheral vascular disease, dysrhythmia, cancer, severe behavioural disorder, mobility and baseline serum albumin concentration. Model discrimination was moderate c-statistic in the internal validation cohort was 0.

A second risk prediction model estimating risk of death at 6 months following dialysis initiation in older people [ 16 ], developed and internally validated in smaller cohorts from the same registry, had slightly inferior model discrimination c-statistic 0. On a regular basis implies 6—8 weekly for dialysis patients and at least at every clinic visit for patients with CKD stage 3b—5 who are not yet on dialysis.

Definition and Incidence

Frailty scores are interlinked with functional status and can provide additional information during assessment and shared decision making on management options. CKD is an independent risk factor for functional impairment and frailty and functional decline is associated with adverse outcomes including excess mortality and hospitalization [ 17 ]. There is also evidence that interventions may reduce functional decline [ 18 ].

Several tools have been developed to assess the various domains of physical function in patients with CKD [ 19 ]. These have been categorized into laboratory-based measures of physiologic impairment, measures of mobility and performance capacity, which are either self-reported or obtained from field tests, and measures of physical activity. There is, however, no consensus on the most appropriate tool for assessing physical function in older patients with advanced CKD. Evidence suggests that functional decline in older patients with CKD can feasibly be assessed using a combination of self- reporting and field tests.

The evidence suggests that all simple scores and tests perform reasonably well. None stands out as being specifically relevant for this particular cohort. Self-report measures of physical performance are simple, easy to use, reliable with good internal consistency, and predictive of adverse outcomes including mortality and hospitalization. It is unclear though, how sensitive they are to changes over time.

Field tests of mobility and physical performance such as sit to stand, gait speed and the 6-min walk have been validated in cohorts that include older CKD patients. They have been shown to have good test—retest and interrater reliability, while also being predictive of adverse outcomes. They have also been shown to respond to interventions aimed at improving functional status.

Physiologic measures such as vO2 max are difficult to incorporate into practice and have a limited role in this setting. This can ideally be achieved by involving a clinical physiotherapist to prescribe a mix of strength and endurance exercises on a regular basis within the physical limitations of the patient. In patients on haemodialysis exercise training can be administered during the first 2 h of the dialysis session. The evidence on positive outcomes of exercise tends to originate from programmes benefitting from intensive involvement of motivated physiotherapy teams.

There is little evidence that augmented dialysis improves functional status in the absence of multidisciplinary physiotherapy and nutritional interventions. Due to the aging of the CKD population and the associated increase of frailty in this group, it is important to formulate guidelines on how to maintain or improve functional status in an older CKD population.

The available evidence is consistent in supporting a positive impact on the physical, functional and psychological well being of CKD patients who perform exercise. Older patients with CKD were able to respond with increased physical function to exercise training. None of the studies reported any adverse events or negative effects, which supports the safety and feasibility of exercise training in this setting.

Treatment decisions for older adults with advanced chronic kidney disease

However all patients had been carefully screened by a physician before participation. Furthermore, studies were generally small, and there was a high risk for selection bias. In addition, it is noteworthy that exercise programmes were closely monitored by a team including a physiotherapist, and that most adapted the intensity of the exercise to the individual capacity of the patient.

This may account for some of the benefits described and the lack of adverse events. The guideline development group therefore suggests that exercise programmes are supervised by a physiotherapist as a part of structured multi-disciplinary programme. This may lead to a state of protein-energy wasting, which is common in patients approaching the need for dialysis [ 21 ]. Further deterioration may occur post dialysis initiation and nutritional status is a strong predictor of survival in dialysis patients.

Older patients are at high risk of wasting because of reduced appetite and a high prevalence of multi-morbidity, social isolation and depression. In an aging dialysis population, it is important to identify reliable, easy to use tools that allow routine assessment of nutritional status, so that patients at risk can be considered for further assessment and management.

We found a high degree of consensus among studies that SGA provides an acceptable estimate of nutritional status, is related to relevant patient outcomes morbidity and mortality and that it is sufficiently sensitive to reliably capture changes in nutritional status. SGA is reasonably easy to perform, relatively brief and can thus be used on a routine basis. The guideline development group suggests the use of SGA as a gold standard for routine assessment of nutritional status.

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For older patients on dialysis, a score including serum albumin, body mass index, serum creatinine normalized to body surface area and nPNA may be used to assess nutritional status [ 22 ]. It has been shown to have an acceptable predictive value for mortality and improvements in the score are associated with improved outcomes. External validation though is lacking. Preserving nutritional status should prevail over any other dietary restriction. There is insufficient evidence to prefer intravenous intradialytic nutritional support over oral nutritional support. Improvements in nutritional status have been reported to improve clinical outcomes, but though a variety of nutritional, pharmacological and dialytic interventions have been suggested, hard evidence from well-controlled and sufficiently powered randomized studies is lacking.

For older patients these restrictions often come on top of many other factors that potentially compromise nutritional intake, such as social deprivation, functional and cognitive impairment, multi-morbidity, dental problems, depression and polypharmacy.