Associated factors related to chronic kidney disease progression in elderly patients

Outpatient clinic for older patients with chronic kidney disease: a model of a multidisciplinary care model

BACKGROUND

The number of older patients with chronic kidney disease (CKD) is increasing worldwide. Managing clinical conditions in this population is challenging due to multimorbidity, including frailty, malnutrition, sarcopenia, and functional status impairment. This clinical scenario, in association with the decrease in kidney function, requires specific care.

METHODS

We propose a new care model for older patients with moderate/advanced CKD involving a multidisciplinary and interdisciplinary team. This team includes nephrologists, geriatric physicians, nurses, and dietitians. To achieve the best results, patients' clinical, laboratory and geriatric conditions are routinely assessed to support better shared decision-making.

RESULTS

Since this model was created (July 2017), 607 patients > 60 years old, most of whom had CKD stages 3b to 5, have been seen at least once. Of these, 439 (72.3%) patients have been followed for a median of 19.6 (9.3, 37.1) months, with an average follow-up interval of 4.4 months. At their first visit, most patients were overweight, 68.7% were independent with regard to activities of daily living, and 21.4% had severely impaired functional capacity. Cognitive impairment was found in 40.5% of patients. In 70.1% of the patients, the median decrease in estimated glomerular filtration rate (eGFR) was 1.4 ml/year over time. The change in eGFR did not correlate with age (r = 0.011, p = 0.839). Among patients with CKD stage 4 or 5, 15% decided to not start dialysis based on a shared-decision making process.

CONCLUSION

The proposed multidisciplinary care model for older patients with CKD guides the multiprofessional identification of various conditions that might otherwise go unnoticed, while emphasizing the importance of each healthcare professional. This approach might increase the likelihood of adopting a more holistic view of patients, ultimately leading to better shared decision-making.

Renal and patient outcomes of emergency hemodialysis in elderly individuals: a retrospective cohort study

PURPOSE

The aging population, commonly defined as individuals aged 65 and above, faces an increased risk of kidney-related diseases. This study investigates emergency dialysis in the elderly population, focusing on indications, clinical and laboratory findings, renal status, and mortality rates.

METHODS

The data of 442 elderly patients (≥ 65 years old) who underwent emergency dialysis at a tertiary university hospital were retrospectively examined. Demographics, comorbidities, emergency dialysis indications, clinical presentation, method, complications, pre/post-dialysis status, and follow-up were assessed.

RESULTS

74.9% of the patients had a history of chronic kidney disease (CKD). Emergency dialysis was mainly initiated due to hypervolemia (43.7%) and uremic symptoms (29.2%). Hypotension was the most common dialysis-related complication (34.4%). The mortality rate was 34.6%; among the survivors, 15.2% achieved complete renal recovery, while 32.5% and 52.3% developed dialysis-independent and -dependent CKD, respectively. In multivariate analysis, blood urea, serum sodium, mean arterial pressure, dyspnea, tachypnea, and tachycardia on admission were found to be associated with mortality.

CONCLUSION

Our study provides insights into emergency dialysis challenges in the elderly population, emphasizing the need for personalized interventions and further research to improve care and outcomes in this growing demographic.

CKD Prevalence and Incidence in Older Adults Using Estimated GFR With Different Filtration Markers: The Atherosclerosis Risk in Communities Study

Rationale & Objective

The prevalence of chronic kidney disease (CKD) is known to increase with age; however, creatinine may be a less reliable filtration marker in older adults. Few studies have investigated the prevalence and progression of CKD using different filtration markers for estimating glomerular filtration rate (GFR).

Study Design

A prospective observational cohort study.

Setting & Participants

6,393 White and African American participants aged 65-100 years from the Atherosclerosis Risk in Communities Study (ARIC) at Visit 5, followed longitudinally at Visits 6 and 7.

Exposure and Outcome

The eGFR was estimated either by creatinine (eGFRcr), cystatin C (eGFRcys), creatinine and cystatin C (eGFRcr-cys), or using creatinine, cystatin C, and β-2-microglobulin (eGFRcr-cys-b2m). CKD progression was defined as 30% decline in eGFR at follow-up visits.

Analytical Approach

Logistic regression models, adjusted for sex, race and study center, diabetes, blood pressure, body mass index, prevalent cardiovascular disease, and heart failure.

Results

At Visit 5, the mean age in the study population was 75.8 years, and the mean eGFR ranged from 71.2 to 61.2 mL/min/1.73m2 using eGFRcr or eGFRcys, respectively. The proportion with eGFR < 60 mL/min/1.73m2 was lowest with eGFRcr and highest with eGFRcys for all age groups, and prevalence increased with age for all markers. For example, the prevalence of eGFRcr < 60 mL/min/1.73m2 in ages 70-74 years ranged from 15% to 21% and in ages 85-89 years ranged from 38% to 46% at the different visits. The proportion with a 30% eGFR decline over a mean of 8 years in people who were originally aged 65-69 years ranged from 9% (eGFRcr)-18% (eGFRcys). More people with eGFRcr ≥ 60 mL/min/1.73m2 were reclassified to < 60 mL/min/1.73m2 when using eGFRcys (33%) compared with eGFRcr-cys (12%) or eGFRcr-cys-b2m (18%). The proportion with 30% eGFR decline was lowest with eGFRcr and highest with eGFRcys, with greater incidence in older age groups for all markers.

Limitations

No direct measurement of GFR. Not all participants survived or attended subsequent follow-up visits.

Conclusions

The prevalence and progression of CKD increase with age, but estimates vary with the filtration marker used. The eGFRcr gave the lowest estimate of CKD at 15% for people aged 65-69 years at Visit 5 while eGFRcys gave the highest estimates of CKD at 26% for that same population.

Management of chronic kidney disease: The current novel and forgotten therapies

Chronic kidney disease (CKD) is a progressive and incurable condition that imposes a significant burden on an aging society. Although the exact prevalence of this disease is unknown, it is estimated to affect at least 800 million people worldwide. Patients with diabetes or hypertension are at a higher risk of developing chronic kidney damage. As the kidneys play a crucial role in vital physiological processes, damage to these organs can disrupt the balance of water and electrolytes, regulation of blood pressure, elimination of toxins, and metabolism of vitamin D. Early diagnosis is paramount to prevent potential complications. Treatment options such as dietary modifications and medications can help slow disease progression. In our narrative review, we have summarized the available therapeutic options to slow the progression of chronic kidney disease. Many new drug treatments have recently become available, offering a beacon of hope and optimism in CKD management. Nonetheless, disease prevention remains the most critical step in disease management. Given the significant impact of CKD on public health, there is a pressing need for further research. With the development of new technologies and advancements in medical knowledge, we hope to find more effective diagnostic tools and treatments for CKD patients.

Predictors of chronic kidney disease survival in type 2 diabetes: a 12-year retrospective cohort study utilizing estimated glomerular filtration rate

Predicting the course of kidney disease in individuals with both type 1 and type 2 diabetes mellitus (DM) is a significant clinical and policy challenge. In several regions, DM is now the leading cause of end-stage renal disease. The aim of this study to identify both modifiable and non-modifiable risk factors, along with clinical markers and coexisting conditions, that increase the likelihood of stage 3-5 chronic kidney disease (CKD) development in individuals with type 2 DM in the United Arab Emirates (UAE). This was a single-center retrospective cohort study based on data derived from electronic medical records of UAE patients with DM who were registered at outpatient clinics at Tawam Hospital in Al Ain, UAE, between January 2011 and December 2021. Type 2 DM patients aged ≥ 18 years who had serum HbA1c levels ≥ 6.5% were included in the study. Patients with type 1 DM, who had undergone permanent renal replacement therapy, who had under 1 year of follow-up, or who had missing or incomplete data were excluded from the study. Factors associated with diabetic patients developing stage 3-5 CKD were identified through Cox regression analysis and a fine and gray competing risk model to account for competing events that could potentially hinder the development of CKD. A total of 1003 patients were recruited for the study. The mean age of the study cohort at baseline was 70.6 ± 28.2 years. Several factors were found to increase the risk of developing stage 3-5 CKD: advancing age (HR 1.005, 95% CI 1.002-1.009, p = 0.026), a history of hypertension (HR 1.69, 95% CI 1.032-2.8, p = 0.037), a history of heart disease (HR 1.49, 95% CI 1.16-1.92, p = 0.002), elevated levels of serum creatinine (HR 1.006, 95% CI 1.002-1.010, p = 0.003), decreased levels of estimated glomerular filtration rate (eGFR) (HR 0.943, 95% CI, 0.938-0.947; p < 0.001), and the use of beta-blockers (HR 139, 95% CI 112-173, p = 0.003). Implementing preventative measures, initiating early interventions, and developing personalized care plans tailored to address specific risk factors are imperative for reducing the impact of CKD. Additionally, the unforeseen findings related to eGFR highlight the ongoing need for research to deepen our understanding of the complexities of kidney disease.

Prevalence of and factors associated with uncontrolled hypertension among patients with early chronic kidney disease attending tertiary hospitals in Dodoma, Tanzania: a cross-sectional study

OBJECTIVE

To determine the prevalence of uncontrolled hypertension and its associated factors among patients with early chronic kidney disease (CKD) attending medical outpatient clinics at tertiary hospitals in Dodoma, Tanzania.

DESIGN

Cross-sectional study.

SETTING

Two tertiary hospitals in Dodoma, Tanzania.

PARTICIPANTS

The participants in this study were adult patients (≥18 years) with early CKD stages (1, 2 and 3) who were attending nephrology and medical outpatient clinics from November 2020 to March 2021. Patients who had been attending the clinic for at least 3 months, had baseline clinical data on their files, had estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 and who provided written informed consent were eligible. A total of 352 patients were enrolled, of whom 182 were men and 170 were women.

OUTCOME MEASURE

The dependent variable was uncontrolled hypertension among patients with early CKD, based on blood pressure measurements.

RESULTS

The prevalence of hypertension was 58.5% (206 of 352) and the prevalence of uncontrolled hypertension was 58.3% (120 of 206). Among patients with uncontrolled hypertension, 88.3% (106 of 120) had CKD stage 3, 80.2% (96 of 120) reported non-adherence to antihypertensives, 76.7% (92 of 120) were overweight or obese, 72.5% (87 of 120) reported current alcohol use and 26.7% (32 of 120) had diabetes mellitus. Factors that contributed to higher odds of uncontrolled hypertension were: age ≥50 years (OR=5.17, 95 % CI 2.37 to 13.33, p=0.001), alcohol use (OR=11.21, 95% CI 3.83 to 32.84, p=0.001), non-adherence to antihypertensives (OR=10.19, 95% CI 4.22 to 24.61, p=0.001), overweight/obesity (OR=6.28, 95% CI 2.54 to 15.53, p=0.001) and CKD stage 3 (OR=3.52, 95% CI 1.32 to 9.42, p=0.012).

CONCLUSION

Uncontrolled hypertension was highly prevalent among patients with early CKD in this setting and was associated with age, current alcohol use, non-adherence to antihypertensives, overweight/obesity and declining eGFR.

Older patients are less prone to fast decline of renal function: a propensity-matched study

PURPOSE

Despite CKD is common among older patients, and although factors associated with CKD progression have been explored over decades, little is known about the decline of renal function specifically in older individuals.

METHODS

We included adult patients with CKD on conservative management in a propensity-score matched study 1:1 older (> 65 year) and young (≤ 65 yr). Factors associated with the slope of the decline of eGFR such as proteinuria, initial eGFR, diabetes, sex, and use of angiotensin-converting enzyme inhibitor/angiotensin receptor block (ACEI/ARB) were analyzed. Inclusion criteria were at least two consultations in the service and an initial eGFR lower than 45 ml/min/m2, in the period between January 2012 and December 2017.

RESULTS

Crude analysis of eGFR decline shows a slower progression of older patients when compared to younger patients in both absolute change [- 2.0 (- 4.5, - 1.0) vs. -3.0 (- 7.0, - 1.0) ml/min/1.73m2, p < 0.001] and slope of eGFR reduction [- 2.2 (- 4.4, - 1.0) vs. 3.1 (- 6.7, - 1.2)) ml/min/1.73m2, p < 0.001]. Patients considered fast progressors (> 5 ml/min/1.73 m2/year decline in eGFR) were less likely to be older (35.2% young vs. 22.0% older, p < 0.001). Adjusted logistic multivariate regression confirmed that older patients had less odds ratio of eGFR decline, independently of the presence of proteinuria, diabetes, ACEI/ARB use, sex, baseline eGFR, baseline phosphate and baseline 25(OH) vitamin D.

CONCLUSION

Older patients present slower CKD progression even after multiple adjustments. This information should be taken into consideration while treating these patients on conservative management and should be kept in mind while planning dialysis start.

Prognostic significance of albuminuria in elderly of various ages with diabetes

It remains uncertain whether albuminuria can identify elderly patients with diabetes at a high risk of incident end-stage kidney disease (ESKD) or mortality. 3065 patients (aged ≥ 65 years) with type 2 diabetes were included. We examined the association between albuminuria stages (normoalbuminuria, A1; microalbuminuria, A2; and macroalbuminuria, A3) and the risk of incident ESKD and all-cause mortality for each age group (65-69, 70-74, and ≥ 75 years). A2 and A3 were observed in 25.5% and 9.4% of the subjects, respectively. For A1, A2, and A3, the probabilities of ESKD at 8 years were 1.0%, 6.3%, and 29.7% (P < 0.001 for all), and the all-cause mortality was 13.1%, 27.4%, and 31.7% (P < 0.001 for A1 vs A2, P < 0.001 for A1 vs A3), respectively. Albuminuria stages were independently associated with an increased risk of ESKD [fully adjusted hazard ratios (HR): 3.650 (1.987-6.702) for A2, 10.404 (5.706-18.972) for A3 vs. A1]. The HRs of all-cause mortality were 1.742 (1.411-2.153) for A2 and 1.810 (1.344-2.441) for A3. The associations between albuminuria stages and the risk of ESKD and all-cause mortality were consistent across all age groups. Even microalbuminuria is also a risk factor for incident ESKD and mortality in elderly patients with diabetes.

Magnesium in Kidney Function and Disease-Implications for Aging and Sex-A Narrative Review

Magnesium (Mg) has a vital role in the human body, and the kidney is a key organ in the metabolism and excretion of this cation. The objective of this work is to compile the available evidence regarding the role that Mg plays in health and disease, with a special focus on the elderly population with chronic kidney disease (CKD) and the eventual sex differences. A narrative review was carried out by executing an exhaustive search in the PubMed, Scopus, and Cochrane databases. Ten studies were found in which the role of Mg and sex was evaluated in elderly patients with CKD in the last 10 years (2012-2022). The progression of CKD leads to alterations in mineral metabolism, which worsen as the disease progresses. Mg can be used as a coadjuvant in the treatment of CKD patients to improve glomerular filtration, but its use in clinical applications needs to be further characterized. In conclusion, there's a need for well-designed prospective clinical trials to advise and standardize Mg supplementation in daily clinical practice, taking age and sex into consideration.

Association of exposure to multiple serum metals with the risk of chronic kidney disease in the elderly: a population-based case-control study

In the world, chronic kidney disease (CKD) has been recognized as one of the critical public health problems, and the prevalence is higher in the elderly people. However, there are few studies on the association between exposure to multiple serum metal levels and CKD. A case-control study, we established, for elderly people in Anhui Province, China, to explore the effects of different metals and analyze the effect of mixed exposure on CKD. In this study, 287 cases of CKD and 287 controls were selected in the elderly health physical examination project in Tongling City, Anhui Province. Questionnaire survey, physical examination, and blood collection were conducted. Graphite furnace atomic absorption spectrometry (GFAAS) and inductively coupled plasma optical emission spectrometry (ICP-OES) were used to measure the concentration of serum metals. After selecting by least absolute shrinkage and selection operator (LASSO), 5 metals were brought into the multi-metal model. After adjusting all potential covariates additionally, the concentrations of lead (Pb), cadmium (Cd), cobalt (Co), and manganese (Mn) were significantly associated with CKD risk, whereas Pb, Se, and Cd had significant non-linearity with CKD. Besides, patients with highest quartiles of cobalt (Co), lead (Pb), and manganese (Mn) were 1.64, 1.39, and 0.64 times more possible to have CKD, respectively, as compared with the lowest levels. In the Bayesian kernel machine regression (BKMR) model, cadmium (Cd) had a combined effect with lead (Pb) possibly. This study suggested that the CKD risk was associated with exposure of multiple metals in elderly people. The underlying mechanisms of serum metals and CKD need more experimental and prospective studies to elucidate.

The Effect of Dietary Phosphorus Restriction on Urine Protein Excretion in Patients With Proteinuria: A Randomized Controlled Trial

OBJECTIVES

The present study was designed to determine the effect of dietary phosphorus restriction, independent of protein intake, on the urinary protein excretion in patients with proteinuria.

METHODS

Seventy-one patients with proteinuria were enrolled in a parallel randomized controlled trial study. The patients were randomly allocated to receive either a recommended phosphorus-restricted diet (n = 36) or a recommended control diet (n = 35), for 8 weeks. A diet was designed and recommended to participants in a way that both trial groups would receive the same amount of energy and protein and the only significant difference between them was the amount of phosphorus intake. The study outcomes included the changes in spot urine protein-to-creatinine ratio, the changes in serum and urine levels of phosphorus, as well as the changes in estimated glomerular filtration rate (eGFR).

RESULTS

The mean ± standard deviation of age, body mass index, and eGFR of the participants were 59 ± 14 years, 29 ± 5.5 kg/m2, and 56.1 ± 21.7 mL/min/1.73 m2, respectively. The amount of phosphorus intake decreased significantly in the phosphorus-restricted group compared to the control one (-709 vs. -369 mg/day; P < .001). This decrease is accompanied by a significant reduction in urine protein-to-creatinine ratio in the phosphorus-restricted group; however, this change did not reach a significant level when compared to the control one (the mean change: -75.78 vs. -55.25 mg/g; P = .539). Limiting the phosphorus intake did not change its serum and urine values as well as eGFR at the end of the trial.

CONCLUSIONS

Although adherence to a phosphorus-restricted diet by patients with proteinuria led to a significant decrease in urinary protein excretion, this change was not significantly different from that of the control diet. Further studies with larger sample sizes and different designs will reveal more evidence for a link between phosphorus intake and proteinuria.

Does delivering more dialysis improve clinical outcomes? What randomized controlled trials have shown

Some randomized controlled trials (RCTs) have sought to determine whether different dialysis techniques, dialysis doses and frequencies of treatment are able to improve clinical outcomes in end-stage kidney disease (ESKD). Virtually all of these RCTs were enacted on the premise that 'more' haemodialysis might improve clinical outcomes compared to 'conventional' haemodialysis. Aim of the present narrative review was to analyse these landmark RCTs by posing the following question: were their intervention strategies (i.e., earlier dialysis start, higher haemodialysis dose, intensive haemodialysis, increase in convective transport, starting haemodialysis with three sessions per week) able to improve clinical outcomes? The answer is no. There are at least two main reasons why many RCTs have failed to demonstrate the expected benefits thus far: (1) in general, RCTs included relatively small cohorts and short follow-ups, thus producing low event rates and limited statistical power; (2) the designs of these studies did not take into account that ESKD does not result from a single disease entity: it is a collection of different diseases and subtypes of kidney dysfunction. Patients with advanced kidney failure requiring dialysis treatment differ on a multitude of levels including residual kidney function, biochemical parameters (e.g., acid base balance, serum electrolytes, mineral and bone disorder), and volume overload. In conclusion, the different intervention strategies of the RCTs herein reviewed were not able to improve clinical outcomes of ESKD patients. Higher quality studies are needed to guide patients and clinicians in the decision-making process. Future RCTs should account for the heterogeneity of patients when considering inclusion/exclusion criteria and study design, and should a priori consider subgroup analyses to highlight specific subgroups that can benefit most from a particular intervention.

Smoothing transition to dialysis to improve early outcomes after dialysis initiation among old and frail adults-a narrative review

The number of patients ≥65 years of age suffering from advanced chronic kidney disease and transitioning to end-stage kidney disease (ESKD) is increasing. However, elderly patients often have poor outcomes once haemodialysis is initiated, including high mortality within the first year as well as fast cognitive and functional decline and diminished quality of life. The question is how we can smooth this transition to ESKD in older patients who also exhibit much higher proportions of frailty when compared with community-dwelling non-dialysis older adults and who are generally more vulnerable to invasive treatment such as kidney replacement therapy. To avoid early death and poor quality of life, a carefully prepared smooth transition should precede the initiation of treatment. This involves pre-dialysis physical and educational care, as well as mental and psychosocial preparedness of the patient to enable an informed and shared decision about the individual choice of treatment modality. Communication between a healthcare professional and patient plays a pivotal role but can be challenging given the high rate of cognitive impairment in this particular population. In order to practise patient-centred care, adapting treatment tailored to the individual patient should include comprehensive conservative care. However, structured treatment pathways including multidisciplinary teams for such conservative care are still rare and may be difficult to establish outside of large cities. Generally, geriatric nephrology misses data on the comparative effectiveness of different treatment modalities in this population of old and very old age on which to base recommendations and decisions.

Unmet needs for CKD care: from the general population to the CKD clinics-how many patients are we missing?

Introduction

Prevalence of chronic kidney disease (CKD) varies around the world. Little is known about the discrepancy between the general population's needs and nephrology care offered. We aimed to contribute to filling this gap and propose a means to infer the number of patients needing follow-up.

Methods

All patients undergoing at least one nephrology consultation in 2019 were enrolled. We used the ratio between CKD Stages 3 and 4 reported in the literature, and considered that only 25–50% of CKD Stage 3 patients have progressive CKD, to hypothesize different scenarios to estimate the number of CKD Stage 3 patients still needing nephrology follow-up.

Results

The 1992 CKD patients were followed-up in our centre (56.93% males; age 66.71 ± 18.32 years; 16.82% Stage 1; 14.66% Stage 2; 39.46% Stage 3; 19.88% Stage 4; 7.68% Stage 5). The ratio between Stages 3 and 4 in population studies ranged from 7.72 to 51.29, being 1.98 in our centre. Hypothesizing that we followed-up 100, 70 or 50% of CKD Stage 4 patients, 528–2506 CKD Stage 3 patients in our area would need nephrology follow-up [1885–8946 per million population (p.m.p.)]. Three to 17 additional nephrologists p.m.p. would be necessary to fully cover the need for care.

Conclusions

The number of patients with CKD Stage 3 who would benefit from nephrology care is high. Considering that one patient-year of delay of dialysis could cover a nephrologist’s annual salary, interventions aimed to improve the care of advanced CKD may be economically sound.

Type 2 Diabetes, Atrial Fibrillation, and Direct Oral Anticoagulation

Type 2 diabetes (T2D) is an independent risk factor of stroke and systemic embolism in patients with atrial fibrillation (AF), and T2D patients with AF-associated stroke seem to have worse clinical outcome and higher risk of unfavorable clinical course compared to individuals without this metabolic disorder. Long-term anticoagulation is indicated in majority of T2D patients with AF to prevent adverse AF-associated embolic events. Direct oral anticoagulants (DOACs), direct oral thrombin inhibitor dabigatran, and direct oral factor Xa inhibitors, rivaroxaban, apixaban, and edoxaban, have emerged as a preferred choice for long-term prevention of stroke in AF patients offering potent and predictable anticoagulation and a favorable pharmacology with low risk of interactions. This article reviews the current data regarding the use of DOACs in individuals with T2D and AF.