Current and emerging treatment options for the elderly patient with chronic kidney disease

Risk Factors of Chronic Kidney Disease Progression: Between Old and New Concepts

Chronic kidney disease (CKD) is a condition characterized by the gradual loss of kidney function over time and it is a worldwide health issue. The estimated frequency of CKD is 10% of the world's population, but it varies greatly on a global scale. In absolute terms, the staggering number of subjects affected by various degrees of CKD is 850,000,000, and 85% of them are in low- to middle-income countries. The most important risk factors for chronic kidney disease are age, arterial hypertension, diabetes, obesity, proteinuria, dyslipidemia, and environmental risk factors such as dietary salt intake and a more recently investigated agent: pollution. In this narrative review, we will focus by choice just on some risk factors such as age, which is the most important non-modifiable risk factor, and among modifiable risk factors, we will focus on hypertension, salt intake, obesity, and sympathetic overactivity.

Frailty predicts increased risk of reintervention in the 2 years after arteriovenous fistula creation

INTRODUCTION

Frailty is associated with adverse survival and increased hospital use in patients with end-stage kidney disease (ESKD). Dialysis access failure is an important source of morbidity and mortality for these patients. There is limited evidence about the interactions between frailty and haemodialysis access failure. This population-based cohort study aimed to determine if haemodialysis access reintervention was predicted by frailty.

METHODS

Routinely-collected hospital data linked with death records were analyzed for all patients with ESKD who had a new arteriovenous fistula or graft (AVF) created between 2010 and 2012 in New South Wales, Australia. Frailty risk was assigned by the Hospital Frailty Risk Score. Multivariate Cox-proportional hazard ratios (HR), adjusted for patient and procedural variables, quantified if frailty was prognostic for adverse haemodialysis access outcomes in the 2 years after AVF creation.

RESULTS

Almost one quarter of the 2302 patients who had a new AVF created during the study period were classified as high frailty risk (554, 24.1%). Compared to low frailty risk patients, patients with high frailty had a significantly greater risk of reintervention for AVF failure in the 2 years after creation (HR 1.68; 95% CI 1.45-1.96), adjusted for age, sex and prior AVFs. Frailer patients were also more likely to have perioperative complications, longer hospital length of stay and readmission to hospital. Frailty was associated with a higher risk of mortality at 2 years after AVF creation (adjusted HR 2.65; 95% CI 1.72-4.10).

CONCLUSION

Frailty predicted adverse haemodialysis access outcomes, with frailer patients having higher rates of AVF reinterventions. These results can assist clinicians engaging in shared decision-making discussions about dialysis access risks and help personalize dialysis access decisions.

Older Age is Associated With Lower Utilization of Living Donor Kidney Transplant

Introduction

Older adults (65 years or older) constitute a substantial and increasing proportion of patients with kidney failure, potentially needing kidney replacement therapy. Living donor kidney transplant (LDKT) offers superior outcomes for suitable patients of all ages. However, exploring LDKT and finding a living donor could be challenging for older adults. Here, we assessed the association between age and utilization of LDKT and assessed effect modification of key variables such as ethnicity and language.

Methods

This is a retrospective cohort study of patients with kidney failure referred for kidney transplant (KT) assessment in Toronto between January 2006 and December 2013. The association between age and having a potential living donor identified was assessed using logistic regression and the association between age and the receipt of LDKT was assessed using Cox proportional hazards models.

Results

Of the 1617 participants, 50% were middle-aged (45-64 years old), and 17% were ≥65 years old. In our final multivariable adjusted models, compared to young adults, middle-aged and older adults had lower odds of having a potential living donor identified (odds ratio [OR], 0.47; confidence interval [CI], [0.35-0.63]; OR, 0.30; CI, [0.20-0.43]; P < 0.001, for middle-aged and older adults, respectively), and were less likely to receive LDKT (hazard ratio [HR], 0.79; CI, [0.63-0.99]; P = 0.04; HR, 0.47; CI, [0.30-0.72]; P = 0.001, for middle-aged and older adults, respectively.).

Conclusion

Age is an independent predictor of receiving LDKT. Considering that nearly 90% of patients with kidney failure in Canada are >45 years of age, these results point to important and potentially modifiable age-related barriers to LDKT.

Comorbidity in chronic kidney disease: a large cross-sectional study of prevalence in Scottish primary care

Background

Chronic kidney disease (CKD) is commonly comorbid with hypertension, diabetes, and cardiovascular disease (CVD). However, the extent of comorbidity in CKD across a range of concordant (shared pathophysiology and/or treatment) conditions and discordant (unrelated pathophysiology and/or different or contradictory treatment) conditions is not well documented.

Aim

To ascertain the prevalence of comorbidity, across 39 physical and mental health comorbidities, in adults with CKD in a large, nationally representative primary care population.

Design and setting

Cross-sectional analysis of a primary care dataset representing 1 274 374 adults in Scotland.

Method

This study was a secondary analysis of general practice electronic medical record data using binary logistic regression models adjusted for age, sex, and socioeconomic status. Data of adults aged ≥25 years and 40 long-term conditions were used.

Results

A total of 98.2% of adults with CKD had at least one comorbidity, versus 51.8% in controls. After adjustment for age, sex, and deprivation, people with CKD were more likely to have 1 (adjusted odds ratio [aOR] 6.5, 95% confidence interval [CI] = 6.0 to 7.1), 2–3 (aOR 15.2, 95% CI = 14.0 to 16.5), 4–6 (odds ratio [OR] 26.6, 95% CI = 24.4 to 28.9), and ≥7 other conditions (OR 41.9, 95% CI = 38.3 to 45.8). Furthermore, all concordant (seven out of seven), the majority of discordant physical health conditions (17 out of 24), and mental health conditions (six out of eight) had statistically significant positive associations with CKD after adjustment.

Conclusion

Chronic kidney disease is associated with extreme comorbidity across a wide range of mental and physical conditions. Routine care for people with CKD should include recognition and management of comorbidities, and clinical guidelines should support clinicians to do this.

Kidney aging process and the management of the elderly patient with renal impairment (Review)

As life expectancy increases, a rise in the number of chronically ill patients is observed due to the aging population. Among the various diseases, chronic kidney disease is at present one of the main causes of morbidity and, due to its typical complications, it is also one of the most important causes of mortality in the general population. For these reasons, the understanding of the kidney aging process, its consequences and its adequate management are essential. The judicious use of certain types of drugs, the prevention of episodes of renal injury either by toxic mechanisms or by dehydration are important aspects and are part of the apropriate approach for elderly patients. The most effective treatment of various types of conditions with a negative impact on renal function and for which an increased incidence is known as we age should also be considered. Thus, in the case of elderly patients, in order to protect the kidneys, an integrative approach is recommended, one that includes both elements of prevention and the appropriate treatment of existing diseases.

The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article

Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.

Impact of Renal Transplantation and Immunosuppressive Therapy on Muscle Strength, Functional Capacity, and Quality of Life: A Longitudinal Study

Renal transplantation is the best long-term treatment option compared with maintenance dialysis in patients with chronic kidney disease. This treatment should be combined with immunosuppressive drugs to obtain positive effects; however, the adverse effects of these medications in the respiratory and peripheral muscle strength, functional capacity, and quality of life of patients remain unknown.

OBJECTIVE

The objective of this study is to evaluate the respiratory and peripheral muscle strength, functional capacity, and quality of life of patients undergoing renal transplantation in the preoperative period and during the first 6 months of postoperative period.

METHODS

The respiratory and peripheral muscle strength, quality of life, and functional capacity of 40 patients were evaluated from the pretransplant period to 6 months post-renal transplantation.

RESULTS

Compared with the preoperative period, the patients experienced improvement of the respiratory and peripheral strength 6 months after transplant (maximal inspiratory pressure 44% and maximal expiratory pressure 28.96%, handgrip 13.81%, and lower limbs 26.95%) and also in the quality of life.

CONCLUSION

We conclude that 6 months after transplant, patients showed improvement in respiratory and peripheral muscle strength and quality of life, but even with the improvement, patients presented an unsatisfactory quality of life and muscle strength, regardless of immunosuppressive therapy.

Clinical Characteristics, Patient and Technique Survival in Elderly Patients on Peritoneal Dialysis

The outcomes of the elderly population on peritoneal dialysis (PD) in developing countries are less known. In this study, we intended to study the clinical characteristics and patient and technique survival of elderly patients on PD. In this study, data of 148 elderly patients with end-stage renal disease who initiated PD between January 2001 and December 2015 were collected. Baseline clinical characteristics and events during the study period were recorded. Overall patient and technique survival rates of diabetic and non-diabetic elderly patients on PD were analyzed. Around 128 patients who were initiated PD during the study period were included for final analysis. The mean age of the study group was 70.3 ± 5.1 years, and 94 (80%) were males. Among these, 79 (65.8%) had diabetes. At the end of the study period, only 20 (16.6%) patients were remained on PD. Eighty-four (70%) patients died during PD and 15 (12.5%) patients were transferred to hemodialysis during the study period. The main reasons for death were cardiovascular (56.6%) and sepsis due to peritonitis (18.8%). The mean patient survival time was 38.2 ± 2.6 months. The patient survival rates were 91.2%, 45.3%, and 22.8% at 1, 3, and 5 years, respectively. Predictors of mortality were increased serum phosphorus, peritonitis episodes, urine output <400 mL, and ultrafiltration <1000 mL/day at beginning of PD. The mean technique survival time was 92.0 ± 5.1 months. Technique survival rates at 1, 3, and 5 years were 94.8%, 85.3%, and 71.7%, respectively. None of the factors was found to be predictive of technique survival. We found no significant difference between diabetic and non-diabetic patients in terms of technique and patient survival. Mortality was higher in elderly patients on PD. Factors affecting mortality in elderly patients on PD are low urine output, low ultrafiltration at beginning of PD, high serum phosphorus, and presence of peritonitis episodes. Patient and technique survival rates were comparable between diabetic and non-diabetic elderly patients on PD.

The prevalence of depression and the association between depression and kidney function and health-related quality of life in elderly patients with chronic kidney disease: a multicenter cross-sectional study

Purpose: The prevalence of depression and the relationship between depression and kidney function and health-related quality of life (HRQOL) are not well understood in elderly patients with predialysis chronic kidney disease (CKD). This study aimed to evaluate the prevalence of depression and the association between depression and kidney function and HRQOL. Patients and methods: In this cross-sectional study, 1079 elderly participants with CKD were recruited at 32 clinical centers located within 26 cities throughout 24 provinces in China. Demographic information and laboratory analyses were collected. Symptoms of depression were assessed using the 15-item Geriatric Depression Scale (GDS-15). HRQOL was evaluated using the Kidney Disease Quality of Life-36 (KDQOL-36) instrument. Results: The prevalence of depression was 23.0%. The estimated glomerular filtration rate (eGFR) was negatively correlated with the GDS score whether it was treated as a categorical variable (r=-0.097, P=0.001) or as a continuous variable (r=-0.100, P=0.001). Marital status, education level, history of CVD and diabetes, CKD stage and proteinuria confirmed to be independent and significant predictors of depression in patients with CKD. Compared with CKD 1-2 patients, we observed an increase of 0.541 and 4.171 in the odds for developing depression in patients CKD 4 (odds ratio [OR] =1.541; P=0.031) and CKD 5 (odds ratio [OR] =5.171; P<0.001), respectively. We observed negative and significant correlations with the GDS score for the following components: PCS (r=-0.370, P<0.001), MCS (r=-0.412, P<0.001), burden of kidney disease (r=-0.403, P<0.001), symptoms and problems of kidney disease (r=-0.360, P<0.001) and effects of kidney disease (r=-0.355, P<0.001). Depression was an independent and significant predictor of all the subcomponents of the HRQOL. Conclusions: The prevalence of depression in elderly patients with CKD was high and was negatively correlated with kidney function. Depression had a major negative impact on HRQOL.

Conservative Care, Dialysis Withdrawal, and Palliative Care: Results from a Survey of a Non-Profit Dialysis Provider in Germany

BACKGROUND

In Germany, practice patterns of conservative renal care (CRC), dialysis withdrawal (DW), and concomitant palliative care in patients who choose these options are unknown.

METHOD

A survey was designed including 13 structured and one open questions on the management and frequency of CRC and DW, local palliative care structure, and fundamentals of the decision-making process, and addressed to the head physicians of all renal centers (n = 193) of a non-profit renal care provider (KfH - Kuratorium für Dialyse und Nierentransplantation, Neu-Isenburg, Germany).

RESULTS

Response rate was 62.2% (n = 122 centers) comprising 14,197 prevalent dialysis patients and 159,652 renal outpatients. Two-thirds of the respondents were men (85% in the age group between 45 and 64 years). Mean time of experience in renal medicine was 22.2 years in men, 20.8 years in women. 94% of all centers provided CRC with a different frequency and proportion of patients (mean 8.4% of the center population, median 5%, range 0-50%). Mean proportion of DW was 2.85% per year (median 2%, range 1-15%). Physicians and center features were not significantly associated with utilization of CRC or DW. Palliative care management varied including local palliative teams, support by general physicians, or by the renal team itself. Hospice care was only established in patients undergoing CRC. Fundamentals of the decision-making process were the desire of the patient (90% in CRC, 67% in DW). Patients undergoing CRC changed their opinion towards treatment modality "frequently" in 18% of the cases, "occasionally" in 73%. Physicians' decisions were mostly driven by presumed fatal prognosis and poor physical or mental conditions of the individual patient. Different barriers to provide palliative care for the renal population like lack of education in palliative medicine, shortness of staff, lack of financial resources, and local palliative care structures were reported.

CONCLUSION

Compared to international numbers, in Germany, proportion of CRC and DW reported by non-profit renal centers is in the lower range. Center practice of palliative care management varies and is driven by availability of local palliative care resources and presumably by attitudes of the renal teams. Quality of palliative care and the decision-making process need further evaluation.

Low HDL cholesterol as a predictor of chronic kidney disease progression: a cross-classification approach and matched cohort analysis

Emerging epidemiological evidence indicates that low serum high-density lipoprotein cholesterol (HDL-C) levels are associated with the risk of progression of chronic kidney disease (CKD). However, the differences in the influence of serum HDL-C levels on CKD progression in different subcohorts have rarely been examined in detail in previous studies. The aim of this study was to investigate the significance of low serum HDL-C levels as a predictor of disease progression in CKD patients according to sub-analyses using a cross-classified subcohort. We reviewed data obtained from 120 CKD patients. Prognostic factors for renal outcome were identified by the multivariate Cox proportional hazards method. Kaplan-Meier analysis was performed to assess disease progression, which was defined as a > 30% decline in the glomerular filtration rate (GFR), or end-stage renal disease. The mean age of the included participants was 58.3 ± 13.6 years. The subjects were divided into two groups (low HDL-C vs. high HDL-C). The median follow-up period was 112.8 months. The kidney survival rate in the low HDL-C group was significantly lower than that in the high HDL-C group (P < 0.0001). However, the age-stratified analysis showed no difference between the two groups in the cohort of patients ≥ 70 years old. Multivariate Cox regression analyses showed a significant association between low HDL-C [hazard ratio (HR) 4.80, P = 0.009] and a ≥ 30% eGFR decline or ESRD. This association was more evident in the cohort of patients < 70 years old (HR 4.96, P = 0.0165), especially the female subcohort (HR 13.86, P = 0.0033). Multivariate analysis showed a significant correlation between visceral fat area and serum HDL-C levels among both male (P = 0.0017) and female (P = 0.0449) patients. In a propensity score-matched cohort (patients < 70 years old), the kidney survival rate of CKD patients was significantly lower in the low HDL-C group than in the high HDL-C group (P = 0.0364). A low serum HDL-C level is a significant predictor of CKD progression, especially in female patients with CKD under 70 years of age. This finding is of importance to clinicians when determining the expected prognosis of CKD in patients.

Evaluation of Nutrition Risk Screening Score 2002 (NRS) assessment in hospitalized chronic kidney disease patient

Background

Although chronic kidney disease (CKD) patients are particularly prone to malnutrition, systematic nutritional screening is rarely routinely performed during hospitalization. The primary aim of this study was to determine the prevalence of malnutrition (as captured by the nutritional screening score NRS) in hospitalized CKD patients and explore the impact of malnutrition on hospital mortality.

Methods

All patients admitted to the tertiary nephrology department of the University hospital of Bern Inselspital over a period of 12 months were included in this observational study. The risk for malnutrition was assessed within 24h of admission by the NRS. Demographic, clinical, and outcome data were extracted from the patient database. The primary outcome was in-hospital mortality. The secondary outcomes were length of hospitalization and hospitalization costs. Multilevel mixed-effect logistic regression model analysis was performed to determine the association of in-hospital mortality and risk of malnutrition (NRS score≥3).

Results

We included 696 eligible hospitalizations of 489 CKD patients. Hospitalized patients had a median age of 64 years (interquartile range (IQR), 52–72), 35.6% were at risk of malnutrition (NRS≥3). After adjustment for the identified confounders (Case weight, Barthel index, and CKD stage) multivariate analysis confirmed an independent and significant association between higher in-hospital mortality with NRS≥3 [OR 2.92 (95% CI: 1.33–6.39), P<0.001]. Furthermore, in multivariate analysis the risk of malnutrition was associated with longer length of hospitalization [Geometric mean ratio: 1.8 (95% CI: 1.5–2.0), p<0.001] and with increased hospitalization costs [Geometric mean ratio: 1.7 (95% CI: 1.5–1.9), p<0.001]).

Conclusions

Malnutrition in CKD patients, as captured by NRS>3, is highly prevalent among hospitalized CKD patient and associated with prolonged hospital stay and increased in-hospital mortality.

Clinical Update on Nursing Home Medicine: 2016

This is the tenth clinical update. It covers chronic kidney disease, dementia, hypotension, polypharmacy, rapid geriatric assessment, and transitional care.

Astaxanthin in cardiovascular health and disease: mechanisms of action, therapeutic merits, and knowledge gaps

Cardiovascular disease is the main contributor to morbidity and mortality worldwide.

Palliative care for patients with end-stage renal disease: approach to treatment that aims to improve quality of life and relieve suffering for patients (and families) with chronic illnesses

Providing end-of-life care to patients suffering from chronic kidney disease (CKD) and/or end-stage renal disease often presents ethical challenges to families and health care providers. However, as the conditions these patients present with are multifaceted in nature, so should be the approach when determining prognosis and treatment strategies for this patient population. Having an interdisciplinary palliative team in place to address any concerns that may arise during conversations related to end-of-life care encourages effective communication between the patient, the family and the medical team. Through the use of a case study, the authors demonstrate how an interdisciplinary palliative team can be used to make decisions that satisfy the patient's and the medical team's desires for end-of-life care.

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

Bisphosphonates for Osteoporosis in Patients with Renal Insufficiency: Pharmacists' Practices and Beliefs

BACKGROUND

Clinicians often face challenges in deciding how to treat osteoporosis in patients with chronic kidney disease. As background to offering guidance to health care providers, it is important to understand their practices and beliefs.

OBJECTIVES

To describe the practices and beliefs of pharmacists regarding use of bisphosphonates for patients with osteoporosis and chronic kidney disease.

METHODS

A cross-sectional survey of pharmacists working in hospitals and related health care settings was conducted. A 34-item online questionnaire was developed consisting of 4 sections: demographic characteristics, practices, beliefs, and comfort level with making decisions about osteoporosis treatment. An e-mail invitation was sent to members of the Canadian Society of Hospital Pharmacists (n = 2499) in November 2012.

RESULTS

A total of 367 pharmacists completed the survey. Most of the respondents were women (258 [70%]), had more than 10 years in practice (213 [58%]), and were providing care to 1 or more osteoporosis patients per week (212 [58%]). Over one-third (150 [41%]) stated that they would use a bisphosphonate for patients with creatinine clearance (CrCl) of 15-30 mL/min, but more than half (207 [56%]) stated that they would avoid a bisphosphonate (and recommend another medication) for patients with CrCl below 15 mL/min. Forty-eight percent (176/363) agreed that oral bisphosphonates could be used for patients with renal failure (defined as CrCl < 30 mL/min), so long as dosage adjustments are made. More than half (206/363 [57%]) believed that the adverse effects of oral bisphosphonates increase for patients with renal failure. Respondents expressed a low level of comfort in assessing and initiating osteoporosis treatment for patients with renal failure.

CONCLUSIONS

Pharmacists had varying beliefs about managing osteoporosis in patients with chronic kidney disease. This study highlights the need for practice tools and targeted education addressing the use of bisphosphonates for these patients.

Understanding alterations in drug handling with aging: a focus on the pharmacokinetics of maintenance immunosuppressants in the elderly

PURPOSE OF REVIEW

This review presents current knowledge of the impact of age on the pharmacokinetics of maintenance immunosuppressants.

RECENT FINDINGS

Over the past decade, there has been a steady increase in older patients on organ transplant waiting lists. As a result, the average age of transplant recipients has significantly increased. The survival and quality-of-life benefits of transplantation in the elderly population have been demonstrated. Advancing age is associated with changes in immune responses, as well as changes in drug handling. Immunosenescence is a physiological part of aging and is linked to reduced rejection rates, but also higher rates of diabetes, infections and malignancies. Physiologic changes associated with age can have a significant impact on the pharmacokinetics of the maintenance immunosuppressive agents. Taken together, these age-related changes impact older transplant candidates and may have significant implications for managing immunosuppression in the elderly.

SUMMARY

Despite the lack of formal efficacy, safety and pharmacokinetic studies of individual immunosuppressants in the elderly transplant population, there are enough data available for practitioners to be able to adequately manage their older patients. A proficient understanding of the factors that impact the pharmacokinetics of the immunosuppressants in the elderly is essential to managing these patients successfully.

Percutaneous nephrolithotomy in octogenarians and beyond: How old is too old?

Objective

To specifically report perioperative characteristics and outcomes in patients 80 years and older undergoing percutaneous nephrolithotomy (PCNL). PCNL has been established as feasible in the elderly; however, to our knowledge no one has specifically reported feasibility in patients 80 years and older.

Methods

We retrospectively reviewed perioperative data of octogenarians who underwent PCNL at a high stone volume single institution, and matched them to patients <65 years of age by stone burden and sex. Patient demographics, perioperative outcomes and postoperative complications were compared.

Results

Thirty-three octogenarians (mean age 83.6 years) with 36 renal units were matched to 67 controls (mean age 48.6 years) with 72 renal units. Octogenarians had a higher mean American Society of Anesthesiologists (ASA) score, more comorbidities, and worse renal function. There were no differences in operative characteristics, length of hospital stay or stone free rates. Of the patients with preoperative urinary decompression (ureteral stent or nephrostomy tube) prior to PCNL, the elderly were more likely to have a history of urosepsis. Octogenarians did not experience more minor Clavien (I – II) or major Clavien (IIIa – IVb) complications.

Conclusion

Octogenarians who undergo PCNL were more likely to have cardiovascular comorbidities and a prior history of sepsis. Despite these risk factors, in appropriately selected patients PCNL can be safely and successfully performed in octogenarians without increased perioperative complications relative to a younger cohort.

Optimizing outcomes in the elderly with end-stage renal disease--live long and prosper

BACKGROUND

The elderly form an expanding proportion of patients with chronic kidney disease and end-stage renal disease worldwide. The increased physiological frailty and functional morbidity associated with the aging process pose unique challenges when planning optimal management of an older patient needing renal replacement therapy (RRT).

AIMS

This position paper discusses current evidence regarding the optimal management of end-stage renal disease in the elderly with an emphasis on hemodialysis since it is the most common modality used in older patients. Further research is needed to define relevant patient-reported outcome measures for end-stage renal disease including functional assessments and psychological impacts of various forms of RRT. For those older patients who have opted for dialysis treatment, it is important to study the strategies that encourage greater uptake of home-based dialysis therapies and optimal vascular access.

CONCLUSIONS

The management of advanced chronic kidney disease in the elderly can be challenging but also extremely rewarding. The key issue is adopting a patient-focused and individualized approach that seeks to achieve the best outcomes based on a comprehensive holistic assessment of what is important to the patient.

Chronic kidney disease in the elderly: evaluation and management

Chronic kidney disease (CKD) is a very common clinical problem in elderly patients and is associated with increased morbidity and mortality. As life expectancy continues to improve worldwide, there is a rising prevalence of comorbidities and risk factors such as hypertension and diabetes predisposing to a high burden of CKD in this population. The body of knowledge on the approach to elderly patient with CKD is still evolving. Thus, this review seeks to explore the epidemiology and to discuss current understanding of challenges in the diagnosis and management of elderly patients CKD.