Nonprogressive Kidney Dysfunction and Outcomes in Older Adults with Chronic Kidney Disease

El-Ghoul, Balsam; Elie, Caroline; Sqalli, T.; Jungers, Paul; Daudon, Michel; Grünfeld, Jean‐Pierre; Lesavre, Philippe; Joly, Dominique

doi:10.1111/j.1532-5415.2009.02561.x

Cited by 32 publications

(20 citation statements)

References 32 publications

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“…This may not be surprising since more than one-third of the subjects over 80 years of age referred to a nephrology center has a severe but nonprogressive renal dysfunction, and this subgroup has a lower mortality rate than those with a progressive deterioration of the renal function. 20 Indeed, all three patients mentioned above were octogenarians. Obviously, the validity of our findings should be evaluated in detail with a greater accumulation of Japanese subjects with end-stage CKD.…”

Section: Discussionmentioning

confidence: 99%

An Analysis of Elderly End-stage Chronic Kidney Disease Patients Who Did Not Undergo Renal Replacement Therapy in Japan

Akimoto

Ito²,

Takahashi³

et al. 2015

Clinical Medicine Insights: Geriatrics

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ABSTR ACT: There is little descriptive information regarding the conservative management of Japanese end-stage chronic kidney disease (CKD) patients. We carried out a retrospective case series analysis of elderly Japanese end-stage CKD patients who were hospitalized and died without the provision of renal replacement therapy (RRT) programs. A total of 25 consecutive patients followed by a nephrologist for a median of 443 days with a mean age of 81.7 ± 7.5 years were included. The most common symptom on admission was appetite loss in 17 patients (68%). Fifty percent of the patients died within 394 days of follow-up after their estimated glomerular filtration rate (eGFR) fell below 15 mL/min/1.73 m 2 and 222 days of follow-up after the eGFR fell below 10 mL/min/1.73 m 2 . The validity of our findings for Japanese patients with end-stage CKD must be evaluated in greater detail.

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Section: Discussionmentioning

confidence: 99%

An Analysis of Elderly End-stage Chronic Kidney Disease Patients Who Did Not Undergo Renal Replacement Therapy in Japan

Akimoto

Ito²,

Takahashi³

et al. 2015

Clinical Medicine Insights: Geriatrics

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“…Many older CKD patients die long before reaching dialysis because of significant cardiovascular mortality with higher stages of CKD (6,(24)(25)(26)(27)(28)(29). Older adults were 13 times more likely to die of any cause than progress to ESRD and six times more likely to die of cardiovascular disease than develop ESRD (27).…”

Section: Likelihood Of Renal Disease Progression Before Deathmentioning

confidence: 99%

“…Irrespective of baseline renal function, patients over 85 years of age were more likely to die before progressing to the need for dialysis (6), and 30% of octogenarians followed over 4 years died of nonrenal causes before RRT (28). More than one-third of patients over 80 years of age were found to have stable nonprogressive CKD, which was predicted by low levels of proteinuria, lack of hypertension, and low cardiovascular comorbidity (29). Thus, many older patients as well as those patients without deteriorating renal function or proteinuria may not progress to ESRD and the need for RRT.…”

Section: Likelihood Of Renal Disease Progression Before Deathmentioning

confidence: 99%

“…Older patients lose renal function at slower rates than their younger counterparts, have a low incidence of progression to ESRD, and have shorter survival (6,(24)(25)(26)(27)(28)(29). Many older CKD patients die long before reaching dialysis because of significant cardiovascular mortality with higher stages of CKD (6,(24)(25)(26)(27)(28)(29).…”

Section: Likelihood Of Renal Disease Progression Before Deathmentioning

confidence: 99%

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Informing Our Elders About Dialysis

Schmidt

2012

Clinical Journal of the American Society of Nephrology

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SummaryAs the fastest growing sector of the incident ESRD population, older patients constitute a group for which renal replacement therapy has special implications. Older CKD patients have unique needs by virtue of advanced age, high prevalence of comorbid conditions, slower progression of renal disease, and reduced survival. Burdens and risks attendant to dialysis may be amplified in the older patient and patients with impaired functional status or comorbid conditions, and therefore, dialysis may confer little to no survival benefit. Rates of dialysis withdrawal are highest among the oldest patients, raising the possibility that the standard content of informed consent for dialysis warrants an age-sensitive approach that is attuned to the very different balance of pros and cons of dialysis for older patients with multiple comorbidities and younger patients with limited comorbidity. Informed consent for older patients should include presentation of risks, benefits, and burdens associated with dialysis, age-specific estimates of prognosis with and without dialysis, and potential for loss of independence and decline in functional status with initiation of dialysis. In this article, medical evidence and clinical practice guidelines relevant to advance care planning for the older patient with CKD are reviewed, issues to consider in the dialogue with older patients contemplating dialysis are presented, and recommendations for an age-attuned approach to informed consent for older CKD patients are made.

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“…Canadian guidelines now recommend intention-to-defer dialysis (25). This is especially important for the oldest patients because one third of octogenarians with advanced CKD do not progress to ESRD and require only observation and conservative management (54).…”

Section: Beneficence and Nonmaleficence Need To Be Viewed Through Thementioning

confidence: 99%

The Ethics of Chronic Dialysis for the Older Patient

Thorsteinsdottir

Swetz

Albright³

2015

Clinical Journal of the American Society of Nephrology

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Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits. With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis. Nephrologists should ensure that the patient's rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patient's goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases.

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Nonprogressive Kidney Dysfunction and Outcomes in Older Adults with Chronic Kidney Disease

Cited by 32 publications

References 32 publications

An Analysis of Elderly End-stage Chronic Kidney Disease Patients Who Did Not Undergo Renal Replacement Therapy in Japan

An Analysis of Elderly End-stage Chronic Kidney Disease Patients Who Did Not Undergo Renal Replacement Therapy in Japan

Informing Our Elders About Dialysis

The Ethics of Chronic Dialysis for the Older Patient

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