Older Adults with CKD and Acute Kidney Failure

Abstract

Most medical providers argue that they practice patientcentered care: incorporating evidence-based best practices in the context of patient preferences, capacity, and healthcare goals. However, to accomplish true patient-centered care, we must transition from disease-oriented care to patient-oriented care. The foundation of this is shared decision making in which evidence-based best practices are adapted within the patient's context, which is referred to as contextualized care. 1,2 The end result is individualized care that enables patients to achieve the best outcomes based on what is important to them, rather than what is important to the healthcare provider or system. 3 When this approach is successful, it improves overall patient outcomes and possibly decreases unnecessary testing, procedures, and therapy. 3,4 We also know that our patients want and expect accurate, transparent information about their disease trajectory, including symptoms and symptom management, survival, cost of care, and quality of life for each therapy choice. Unfortunately, nephrologists and other providers have not consistently met this expectation. [5][6][7][8] Certainly this gap in information exchange may be due to the nephrology team's lack of awareness, communication skills, or time to spend with the patient; however, it may also be due to the lack of available trusted data that can be interpreted relative to certain subsets of CKD patients. This is particularly true for the older adult with advanced CKD or AKI.A clinical commentary by Rosansky and Clark 9 highlights the recent decline in the number of patients starting renal replacement therapy in the United States. The data presented indicate that the decrease in early dialysis starts (with an estimated GFR $10 ml/min per 1.72 m 2 ) accounts for a large part of this change. Interestingly, there has been a slowdown in early dialysis starts even for individuals aged .75 years, whose increasing incidence of dialysis has outpaced other age groups. Changes in practice patterns leading to the decrease in early starts were influenced by well designed, patientoriented research informing conversations with patients around the timing of and need for renal replacement therapy. [9][10][11][12][13][14][15][16][17][18][19] The knowledge gained from these studies and others about the pros and cons of therapy options, including maximum conservative management, should be incorporated into patient-centered, age-relevant decision aids, a tool that is successful in helping patients understand the effect of various options on their healthcare goals and personal priorities. 20,21 Unfortunately, many elderly patients do not decide whether to pursue renal replacement therapy while they are in calm, controlled preemptive settings. Rather, patients often must make this decision at the time of an acute illness or decompensation of a complex chronic illness, when time pressures and lack of prognostic data hinder the decision making process. 22,23 In these acute situations, especially for very elderly indiv...

High cardiovascular event rates occur within the first weeks of starting hemodialysis

“… 33 , 34 There is an increasing appeal for shared decision making for dialysis initiation, based on evaluation of risks, benefits, quality of life impact, and prognosis. 35 , 36 Based on our findings we believe that an increased risk for CVE after dialysis initiation should be taken into account in such deliberations.…”

Acute Kidney Injury and Subsequent Frailty Status in Survivors of Critical Illness: A Secondary Analysis

“…(46, 48–50) Because patients who survive severe AKI are at the highest risk for developing advanced stages of CKD and ESRD, the high prevalence of frailty in this population suggests that routine assessments be considered. (51) Future studies will need to determine the impact of frailty on recovery from AKI and downstream outcomes and whether interventions that can decrease frailty can improve clinical and patient-centered outcomes. Because survivors of severe AKI often suffer marked declines in quality of life,(25) additional information to guide patient and clinician decision making is essential.…”

Predictors of Outpatient Kidney Function Recovery Among Patients Who Initiate Hemodialysis in the Hospital

“…An AKI episode occurred during hospitalization in 53% and 64% of the total veteran cohort initiated in-hospital RRT. At the time of hospital discharge, patients carry additional burdens of physical debility, infection or wound management, re-hospitalization risk, and/or loss of independence, especially among elderly patients 16,34,35 . As such, the complexity of new outpatient hemodialysis patients who started RRT in the hospital is often overwhelming for both patients and the providers who manage them…”