Clinical Decisions in Elderly Patients with ESRD

1. Clinical Decisions in Elderly Patients with ESRD Donna S. Hanes, M.D., F.A.C.P. Associate Professor of Medicine Director, Internal Medicine Clerkship and Senior Rotations Medical Director, Chestnut Dialysis Unit ACP February 2008

2. Disclosures • No financial or other conflicts of interest

3. Leonid Hurwicz, 1917

4. Millions of individuals (19.2) 5.9 Stage 1 Stage 2 5.3 7.6 Stage 3 0.4 Stage 4 Stage 5 0.3 CKD: An Epidemic Coresh et al. AJKD 2003. 41; 1-12.

5. 100,000 All ESRD 80,000 60,000 Incidence of New Patients 40,000 Diabetes 20,000 Hypertension Glomerulonephritis 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 US Renal Data System. 2000 Atlas of ESRD in the United States.

6. CV Mortality in the General Population and in Patients with Kidney Failure 100 10 GP Male GP Female GP Black GP White Dialysis Male Dialysis Female Dialysis Black Dialysis White Transplant 1 Annual Mortality (%) 0.1 0.01 0.001 25–34 35–44 45–54 55–64 65–74 75–84 > 85 Age (years) Sarnak, MJ et al. Hypertension 2003; 42: 1050-1065.

7. Octogenarians and Nonagenarians Starting Dialysis • Incident dialysis patients 13,577 • 57% increase over 6 years • One year mortality 46% Kurella, Ann Intern Med 2007

8. Age 40 to 44 Age 60 to 64 Age over 65 7 to 11 years 4 to 6 years 5 year survival of 15% Survival Rates

9. Guidelines for Withholding Care • Permanently unconscious • Severe dementia • Severe mental disability • Death imminent within 60 days • End stage disease confined to bed • Unremediable pain • Hospitalized patients with MOF

10. Withdrawal of Dialysis – Third Leading Cause of Death • Shared decision making • Informed consent • Estimate prognosis • Advanced directives • Time limited trials • Palliative care RPA/ASN

11. Initiation of Dialysis • Pericarditis • Encephalopathy • Bleeding • Volume overload • Hypertensive • Refractory metabolic disturbances • Malnutrition

12. Special Considerations in the Elderly • 12 to 20% PCPs (and 9% nephrologists) believe there should be an age limit • Ninety percent less likely to be offered dialysis • Advanced Directives • Dialysis modality • Cost Tussin, AJKD 2004

13. Survival Benefit of Nephrologic Care Tseng, Arch Intern Med 2008

14. Benefits of Early Referral • Informed selection • Timely access placement • Non-emergent initiation of dialysis • Lower morbidity • Lower cost • Improved survival

15. Current Guidelines • PTH • Hg • Calcium and Phosphorus • Protein

16. 75 55 25 15 5 Complications Worsen with Progression of CKD CKD Continuum CKD ESRD Anemia Malnutrition Metabolic acidosis Secondary hyperparathyroidism Hyperkalemia Increasing Severity of Complications GFR (mL/min/1.73 m2) Zabetakis et al. Am J Kidney Dis. 2000; 36(suppl 3):S31-S38.

17. Levin A; Nephro Dial Transplan 2006:21;370-377.

18. Goal Physicians should not be so preoccupied with the preservation of life that they no longer can see the broader human context of their work: to offer some humanity at moments of suffering.

19. Thank you

21. 125 100 Creatinineclearance 75 50 Ucr V Pcr 25 0 0 1 2 3 4 5 6 PcrSerum creatinine (mg/dL) Serum Creatinine Is a Misleading Guide to GFR Implications of doubling of serum creatinine