Prevalence of Moderate and Severe Renal Insufficiency in Older Persons With Hypertension, Diabetes Mellitus, Coronary Artery Disease, Peripheral Arterial Disease, Ischemic Stroke, or Congestive Heart Failure in an Academic Nursing Home

Smart Technologies used as Smart Tools in the Management of Cardiovascular Disease and their Future Perspective

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality worldwide. The advent of smart technologies has significantly impacted the management of CVD, offering innovative tools and solutions to improve patient outcomes. Smart technologies have revolutionized and transformed the management of CVD, providing innovative tools to improve patient care, enhance diagnostics, and enable more personalized treatment approaches. These smart tools encompass a wide range of technologies, including wearable devices, mobile applications,3D printing technologies, artificial intelligence (AI), remote monitoring systems, and electronic health records (EHR). They offer numerous advantages, such as real-time monitoring, early detection of abnormalities, remote patient management, and data-driven decision-making. However, they also come with certain limitations and challenges, including data privacy concerns, technical issues, and the need for regulatory frameworks. In this review, despite these challenges, the future of smart technologies in CVD management looks promising, with advancements in AI algorithms, telemedicine platforms, and bio fabrication techniques opening new possibilities for personalized and efficient care. In this article, we also explore the role of smart technologies in CVD management, their advantages and disadvantages, limitations, current applications, and their smart future.

Clinical and Prognostic Implications of Estimating Glomerular Filtration Rate by Three Different Creatinine-Based Equations in Older Nursing Home Residents

Background

According to the international literature, the percentage of nursing home (NH) residents with renal insufficiency is very high, ranging between 22 and 78%. Diminished kidney function represents a risk factor for drug overdosage, adverse drug reactions, end-stage renal disease, disability, morbidity, and mortality. Several studies suggested that screening for chronic kidney disease (CKD) in high-risk and older populations may represent a cost-effective approach to reducing progression to renal failure and CKD mortality.

Objective

This study aimed (i) to investigate to what extent CKD may be staged interchangeably by three different creatinine-based estimated glomerular filtration rate (eGFR) equations in a sample of older adults living in long-term care facilities; (ii) to investigate factors explaining differences among eGFR equations; and (iii) to compare the predictivity of different creatinine-based eGFR equations with respect to all-cause mortality.

Methods

A total of 522 residents aged 65 years and older participated in a prospective cohort study of 9 long-term care facilities in Calabria. eGFR was calculated by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Berlin initiative study (BIS), and full age spectrum (FAS) equations. Disability in at least one activity of daily living (ADL), depression, cognitive impairment, comorbidity, and malnutrition was considered in the analysis. Statistical analysis was carried out by Bland-Altman analysis, and 2-year mortality was investigated by Kaplan-Meier curves and Cox regression analysis.

Results

Depending on the adopted equation, the prevalence of NH residents with impaired renal function (eGFR < 60 ml/min/1.73 m²) ranged between 58.2% for the CKD-EPI and 79.1% for the BIS1 equation. The average difference between BIS and FAS was nearly negligible (0.45 ml/min/1.73 m²), while a significant bias was detected between CKD-EPI and BIS and also between CKD-EPI and FAS (6.21 ml/min/1.73 m² and 6.65 ml/min/1.73 m², respectively). Although the eGFR study equations had comparable prognostic accuracy in terms of mortality risk, BIS and FAS were able to reclassify NH residents pertaining to a low-risk group with CKD-EPI, and this reclassification improves the discriminative capacity of CKD-EPI with respect to overall mortality.

Conclusion

Despite the relatively good correlation between eGFRs calculated using all adopted equations, the findings in this study reported clearly demonstrated that CKD-EPI and BIS/FAS equations are not interchangeable to assess eGFR among older people and particularly in institutionalized and frail older subjects.

Combined use of drugs inhibiting the renin-angiotensin system: prescribing patterns and risk of acute kidney injury in German nursing home residents

Background/aims

In 2012, the European Medicines Agency reviewed the safety of dual renin-angiotensin system (RAS) blockade because of potentially increased risks for inter alia acute kidney injury (AKI). Since residents of nursing homes are particularly vulnerable to adverse drug outcomes, the aims of our study were to describe RAS-inhibiting drug use in German nursing home residents and examine the risk of AKI associated with dual RAS blockade.

Methods

Based on claims data, a nested case-control study within a cohort of RAS-inhibiting drug users was conducted. Using conditional logistic regression, confounder-adjusted odds ratios (aORs) and 95% confidence intervals (CI) were obtained for the risk of AKI associated with dual RAS blockade. Subgroup analyses were performed in patients with diabetes or chronic kidney disease and both comorbidities.

Results

Of all 127,227 nursing home residents, the study cohort included 64,567 (50.7%) who were treated with at least one RAS-inhibiting drug. More than three quarters of the study population were female (77.1%). Mean age was 86.0 ± 6.8 years. Most residents were treated with angiotensin-converting enzyme inhibitors (77.8%), followed by angiotensin II receptor blockers (21.6%) and aliskiren (0.2%). Annual prevalence of dual RAS blockade declined from 9.6 (95% CI 7.8-11.8) in 2010 to 4.7 (95% CI 4.0-5.4) per 1,000 users in 2014. In the overall cohort, AKI was not significantly associated with dual RAS blockade (aOR 1.99; 0.77-5.17). However, significantly increased aORs were observed when considering patients with diabetes (3.47; 1.27-9.47), chronic kidney disease (4.74; 1.24-18.13) or both (11.17; 2.65-47.15).

Conclusions

Prescribing of drugs inhibiting the RAS is common in German nursing homes. Though the prevalence of dual RAS blockade declined, our study showed an increased risk of AKI in patients with diabetes and/or chronic kidney disease. Therefore, cautious use is warranted in these vulnerable patients.

Inappropriate Medication in Non-Hospitalized Patients With Renal Insufficiency: A Systematic Review

OBJECTIVES

Renal insufficiency is common among older patients and, accordingly, renally excreted drugs may require an adjustment in dosage for them. Rates of non-adherence to renal dosing guidelines range from 19% to 70% across all settings, with the highest rate occurring in outpatient care. However, there is a paucity of research in this field. The main objective of this systematic review is to assess how often drugs are inappropriately prescribed in non-hospitalized patients with renal insufficiency.

DESIGN

A systematic literature search was performed. Data were identified from three electronic databases: PubMed, CINAHL, and Scopus. Studies were included if they reported quantitative data on inappropriate drug use with respect to renal function in non-hospitalized patients.

RESULTS

Our search strategy resulted in 2,403 hits, of which 18 articles satisfied the criteria for inclusion. Mean estimated glomerular filtration rate ranged from 36.0 to 60.4 mL/min. Prevalence of renally inappropriate drug use ranged from 1% to 37% in outpatient settings other than nursing homes, and from 6% to 43% in nursing homes. Eight of the studies we included identified predictors for use of drugs inappropriate for kidney function. Most frequently determined risk factors were increasing age and a high number of prescribed drugs.

CONCLUSION

Lack of dose adjustment for renal impairment seems to be a common problem, even in outpatients. However, the differences in methodologies used in these studies hampered any direct comparison. Accepted and comparable standards regarding the drugs included in the studies as well as estimation of renal function would be beneficial.

Renal Insufficiency and Medication in Nursing Home Residents. A Cross-Sectional Study (IMREN)

BACKGROUND

Nursing home residents often suffer from a multiplicity of medical conditions and take many different drugs. Many drugs are eliminated via the kidneys and thus require dose adjustment in patients with renal insufficiency. This is the first study to address the prevalence of renal insufficiency among nursing home residents in Germany, and the extent to which such persons take drugs that are contraindicated or incorrectly dosed because of renal insufficiency.

METHODS

We carried out a cross-sectional study in nursing homes in the German regions of Bremen and Lower Saxony. Data were collected by nursing staff and given to us anonymously. Whenever the nursing home data did not include a current creatinine value, the patient's general practitioner was asked to supply this value. The estimated creatinine clearance (eCCr) was calculated with the Cockcroft-Gault formula.

RESULTS

852 residents of 21 nursing homes were included in the study; eCCr values were obtainable for 685 (80.4%) of them (average age, 83.3 years; 75.2% female). 48.2% of these patients (95% confidence interval [CI] 41.8-54.5) had moderate renal insufficiency (eCCr 59-30 mL/min), and 15.5% (95% CI 12.4-18.6) had severe renal insufficiency (eCCr <30 mL/min). 19.7% were regularly taking at least one medication that was contraindicated or incorrectly dosed in the light of renal insufficiency. Predictors for such inappropriate drug use were advanced age, female sex, arterial hypertension, and polypharmacy. The drugs that were most often inappropriately used were metformin, ramipril, and potassium chloride.

CONCLUSION

Nursing home residents often suffer from renal insufficiency and should therefore have their creatinine levels measured regularly. A knowledge of the creatinine level is a prerequisite for the proper adjustment of drug doses (if necessary). A practical and compact summary of dose-adjustment recommendations for patients with renal insufficiency would be desirable but is not yet available.

Polypharmacy and Renal Failure in Nursing Home Residents: Results of the Inappropriate Medication in Patients with Renal Insufficiency in Nursing Homes (IMREN) Study

BACKGROUND

Polypharmacy has become an emerging public health issue in recent years, since use of multiple medications or polypharmacy is beneficial for many conditions, but may also have negative effects like adverse drug reactions. The risk further increases in patients with chronic renal failure, a comorbidity very frequent in nursing home residents. Since more than 50% of all drugs were renally excreted, dose adjustments in patients with renal failure are required.

OBJECTIVE

To assess polypharmacy in German nursing homes, in particular in residents with renal failure.

METHODS

Multi-center cross-sectional study in 21 nursing homes in Bremen and Lower Saxony/Germany. Baseline data were analysed using descriptive statistics. Multivariable logistic regression model and 95% confidence intervals were used to study the association of renal failure and polypharmacy.

RESULTS

Of all 852 residents, the analysis comprised those 685 with at least one serum creatinine value so that the estimated creatinine clearance could be calculated. Of those, 436 (63.6%) had a severe or moderate renal failure, defined as estimated creatinine clearance <60 mL/min. Polypharmacy (5-9 drugs) was found in 365 (53.3%) and excessive polypharmacy (≥10 drugs) in 112 (16.4%) residents. Diuretics and psycholeptics were the most commonly used drug classes. Severe renal failure (estimated creatinine clearance <30 mL/min) was associated with polypharmacy (OR: 2.8, 95% CI 1.4-5.7).

CONCLUSION

Both, polypharmacy and renal failure are common in German nursing home residents and an association of both could be found. Further studies are needed to assess the appropriateness of polypharmacy in these patients.

Aging, the metabolic syndrome, and ischemic stroke: redefining the approach for studying the blood-brain barrier in a complex neurological disease

The blood-brain barrier (BBB) has many important functions in maintaining the brain's immune-privileged status. Endothelial cells, astrocytes, and pericytes have important roles in preserving vasculature integrity. As we age, cell senescence can contribute to BBB compromise. The compromised BBB allows an influx of inflammatory cytokines to enter the brain. These cytokines lead to neuronal and glial damage. Ultimately, the functional changes within the brain can cause age-related disease. One of the most prominent age-related diseases is ischemic stroke. Stroke is the largest cause of disability and is third largest cause of mortality in the United States. The biggest risk factors for stroke, besides age, are results of the metabolic syndrome. The metabolic syndrome, if unchecked, quickly advances to outcomes that include diabetes, hypertension, cardiovascular disease, and obesity. The contribution from these comorbidities to BBB compromise is great. Some of the common molecular pathways activated include: endoplasmic reticulum stress, reactive oxygen species formation, and glutamate excitotoxicity. In this chapter, we examine how age-related changes to cells within the central nervous system interact with comorbidities. We then look at how comorbidities lead to increased risk for stroke through BBB disruption. Finally, we discuss key molecular pathways of interest with a focus on therapeutic targets that warrant further investigation.

Molecular mechanisms beyond glucose transport in diabetes-related male infertility

Diabetes mellitus (DM) is one of the greatest public health threats in modern societies. Although during a few years it was suggested that DM had no significant effect in male reproductive function, this view has been challenged in recent years. The increasing incidence of DM worldwide will inevitably result in a higher prevalence of this pathology in men of reproductive age and subfertility or infertility associated with DM is expected to dramatically rise in upcoming years. From a clinical perspective, the evaluation of semen parameters, as well as spermatozoa deoxyribonucleic acid (DNA) integrity, are often studied due to their direct implications in natural and assisted conception. Nevertheless, recent studies based on the molecular mechanisms beyond glucose transport in testicular cells provide new insights in DM-induced alterations in male reproductive health. Testicular cells have their own glucose sensing machinery that react to hormonal fluctuations and have several mechanisms to counteract hyper- and hypoglycemic events. Moreover, the metabolic cooperation between testicular cells is crucial for normal spermatogenesis. Sertoli cells (SCs), which are the main components of blood-testis barrier, are not only responsible for the physical support of germ cells but also for lactate production that is then metabolized by the developing germ cells. Any alteration in this tied metabolic cooperation may have a dramatic consequence in male fertility potential. Therefore, we present an overview of the clinical significance of DM in the male reproductive health with emphasis on the molecular mechanisms beyond glucose fluctuation and transport in testicular cells.

Relationship between renal function and physical performance in elderly hospitalized patients

Chronic kidney disease (CKD) is increasingly recognized as a cause of worsening physical functioning in older patients. The Short Physical Performance Battery (SPPB) is highly reliable in older populations, but no data on older hospitalized patients with different degrees of kidney function are available. We aimed at testing the association between estimated glomerular filtration rate (eGFR) and SPPB, either global score (range 0-12) or its individual components (muscle strength, balance, and walking speed, each ranging from 0 to 4), in a sample of older hospitalized patients. Our series consisted of 486 patients aged 65 or more consecutively enrolled in 11 acute care medical wards participating to a multicenter observational study. eGFR was obtained by the Chronic Kidney Disease Epidemiological Collaboration (CKD-EPI) equation. Physical performance was objectively measured by the SPPB. The relationship between eGFR and SPPB was investigated by multiple linear regression analysis. Physically impaired patients (SPPB total score<5) were older, had lower serum albumin and Mini-Mental State Examination (MMSE) scores as well as higher overall co-morbidity, prevalence of stroke, cancer, and anemia compared to those with intermediate (SPPB=5-8) and good physical performance (SPPB=9-12). Fully adjusted multivariate models showed that eGFR (modeled as 10 mL/min per 1.73 m(2) intervals) was independently associated with the SPPB total score (B=0.49; 95% confidence interval [CI]=0.18-0.66; p=0.003), balance (B=0.30; 95% CI=0.10-0.49; p=0.005), and muscle strength (B=0.06; 95% CI=0.01-0.10; p=0.043), but not with walking speed (B=-0.04; 95% CI=-0.09-0.11; p=0.107). In conclusion, reduced renal function is associated with poorer physical performance in older hospitalized patients. SPPB is worthy of testing to monitor changes in physical performance in elderly CKD patients.

Peripheral arterial disease of the lower extremities

Persons with peripheral arterial disease (PAD) are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped and hypertension, dyslipidemia, diabetes mellitus, and hypothyroidism treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. The serum low-density lipoprotein cholesterol should be reduced to < 70 mg/dl. Antiplatelet drugs such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to persons with PAD. β-Blockers should be given if coronary artery disease is present. Cilostazol improves exercise time until intermittent claudication. Exercise rehabilitation programs should be used. Revascularization should be performed if indicated.

Age and sex variation in prevalence of chronic medical conditions in older residents of U.S. nursing homes

OBJECTIVES

To investigate patterns in prevalences of chronic medical conditions over the age span of long-term stay nursing home residents and between the sexes with data from the 2004 National Nursing Home Survey (NNHS).

DESIGN

Retrospective, cross-sectional study.

SETTING

U.S. nursing homes.

PARTICIPANTS

Nationally representative sample comprising 11,788 long-term stay residents (3,003 (25%) men, 8,785 (75%) women) aged 65 and older.

MEASUREMENTS

Clinical Classifications Software was used to group International Classification of Diseases, Ninth Revision, codes to identify the 20 most-prevalent chronic medical conditions. SAS survey procedures were used to account for design effects of stratification and clustering to generate nationally representative estimates of prevalences of medical conditions.

RESULTS

Average age was 84, with women older than men (85 vs 81, P = .02) and 67% of women aged 80 to 95. Women required more assistance with activities of daily living. The most frequent chronic medical conditions were hypertension (men 53%, women 56%), dementia (men 45%, women 52%), depression (men 31%, women 37%), arthritis (men 26%, women 35%), diabetes mellitus (men 26%, women 23%), gastroesophageal reflux disease (GERD) (men 23%, women 23%), atherosclerosis (men 24%, women 20%), congestive heart failure (CHF) (men 18%, women 21%), cerebrovascular disease (CVD) (men 24%, women 19%), and anemia (men 17%, women 20%). Sex differences in prevalences existed for all but constipation, GERD, and hypertension. Diabetes mellitus, CVD, and lipid disorders decreased with age in men and women. Atrial fibrillation, anemia, arthritis, CHF, dementia, and thyroid disease increased with age in men and women. Age-related patterns differed between the sexes for diabetes mellitus, hypertension, and Parkinson's disease.

CONCLUSION

The profile of chronic medical conditions varies over the age span of nursing home residents and differs between men and women. This knowledge should guide educational and care efforts in long-term care.

Cardiac and renal function are progressively impaired with aging in Zucker diabetic fatty type II diabetic rats

This study investigated the temporal relationship between cardiomyopathy and renal pathology in the type II diabetic Zucker diabetic fatty (ZDF) rat. We hypothesized that changes in renal function will precede the development of cardiac dysfunction in the ZDF rat. Animals (10 weeks old) were divided into four experimental groups: Lean Control (fa/?) LC (n = 7), untreated ZDF rats (n = 7) sacrificed at 16 weeks of age, and LC (n = 7) untreated ZDF rats (n = 9) sacrificed at 36 weeks of age. LV structural/functional parameters were assessed via Millar conductance catheter. Renal function was evaluated via markers of proteinuria and evidence of hydronephrosis. LV mass was significantly less in the ZDF groups at both time points compared to age-matched LC. End diastolic volume was increased by 16% at 16 weeks and by 37% at 36 weeks of age (p < 0.05 vs. LC). End diastolic pressure and end systolic volume were significantly increased (42% and 27% respectively) at 36 weeks of age in the ZDF compared to LC. Kidney weights were significantly increased at both 16 and 36 week in ZDF animals (p < 0.05 vs. LC). Increased urinary albumin and decreased urinary creatinine were paralleled by a marked progression in the severity of hydronephrosis from 16 to 36 weeks of age in the ZDF group. In summary, there is evidence of progressive structural and functional changes in both the heart and kidney, starting as early as 16 weeks, without evidence that one pathology precedes or causes the other in the ZDF model of type II diabetes.

Does concealed chronic kidney disease predict survival of older patients discharged from acute care hospitals?

We aimed at verifying whether unrecognized chronic kidney disease (CKD) (i.e., reduced estimated glomerular filtration rate in spite of normal serum creatinine) has prognostic significance in an unselected population of older patients discharged from 11 acute care hospitals located throughout Italy. Our series consisted of 396 participants aged 70 and older. Estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease (MDRD) study equation. We compared three groups: Normal renal function (normal serum creatinine levels and normal eGFR), concealed (normal serum creatinine levels and reduced eGFR), or overt (increased creatinine levels and reduced eGFR) renal failure. The relationship between renal function and 1-year mortality was evaluated using Kaplan-Meier curves and Cox regression analysis including potential confounders. Overall, 56 patients died over a cumulative follow-up time of 335 months, with an estimated incidence rate of 16.7/100 person-year (PY). The corresponding figures in patients with normal renal function, concealed CKD, and overt CKD were 9.8/100 PY (95% CI, 5.7-15.7), 28.3/100 PY (95% CI, 13.6-52.1), and 23.0 (95% CI, 15.4-33.0), respectively (log rank test p = 0.006). According to the fully adjusted model, both concealed (hazard ratio [HR], 2.35; 95% CI, 1.09-6.01) and overt CKD (HR, 2.09; 95% CI, 1.05-5.34) were significantly associated with the outcome. Concealed CKD contributes to profile the elderly patient at greater risk of death after being discharged from acute care medical wards. If confirmed in broader populations, this finding might have both clinical and epidemiological implications.

Hypertension in the elderly

Many elderly patients have hypertension, although it is more likely to go untreated in this population. Treatment goals are the same in elderly patients as in younger patients, but elderly patients are more likely to have multiple comorbidities, which must be factored into treatment plans. This article highlights the unique challenges in treating this population.

Prevalence and severity of chronic kidney disease and anemia in the nursing home population

OBJECTIVES

Chronic kidney disease (CKD) is an emerging health concern and may have important implications for the management of older people with many other chronic conditions, such as the nursing home (NH) resident population. This study was designed to describe the prevalence of CKD and associated comorbidities in a representative sample of NH residents.

DESIGN

Cross-sectional descriptive study as a component of a prospective observational study of CKD and anemia in the NH population.

SETTING

Eighty-two geographically representative NHs in the United States.

PARTICIPANTS

Participants were 794 NH residents who had complete baseline data collected.

MEASUREMENTS

Residents for whom consent was obtained underwent a record review focused on identifying a predefined set of comorbid conditions, clinical assessment, and blood and urine collections. Stage of CKD was based on estimated GFR (eGFR) using the MDRD equation: no CKD (eGFR > 60 mL/min/1.73 m(2)), Stage 3a (45-59), Stage 3b (30-44), and Stage 4/5 (< 30).

RESULTS

Consent was obtained from 847 of 1626 residents screened; 32 were ineligible and 21 dropped out of the study; complete data were available for 794 residents. CKD was present in approximately 50% of residents; of these residents with CKD, 47.6% were stage 3a, 39.27% stage 3b, and 13.2% stage 4/5. Fifty percent of the population had anemia, and anemia was more common in those with CKD. The average number of comorbid conditions in the population was 5.3 (SD 2.2); the proportion of patients with multiple comorbid conditions, especially cardiovascular conditions, increased with increasing stage of CKD. Among those without CKD, 57% had 5 or more comorbidities in comparison to 87% of those with stage 4/5 CKD.

CONCLUSIONS

In this representative sample of 794 US NH residents, 50% had clinical evidence of CKD. Patients with CKD, particularly those at later stages, were more likely to have cardiovascular comorbidities and anemia. The co-occurrence of these conditions in institutionalized populations may have important implications for the clinical management of this patient population, particularly as it relates to the potential for further renal complications.