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Renal replacement therapy and the elderly. Misha Kotlov, MD July 10, 2007
Renal replacement therapy and the
elderly.
Misha Kotlov, MD
July 10, 2007
Demographics.
Demographics.
► In the US, the primary treatment of geriatric ESRD patients (> 75 yrs) is in-center
► In the US, the primary treatment of geriatric ESRD patients
(> 75 yrs) is in-center hemodialysis (96 %)
► CAPD/CCPD account for approximately 3.5 %
► The average age of the patient undergoing dialysis in the
US has been steadily increasingly over the last several
decades.
► In 2000 the average age was approximately 62 yrs.
► According to United States Renal Data System database,
the number of patients > 80 yrs of age who initiated dialysis
increased from 7054 patients in 1996 to 13,577 individuals
in 2003.
Issues at hand.
Issues at hand.
► Important points to consider when evaluating the treatment of elderly patients with ESRD include: ►
► Important points to consider when evaluating the
treatment of elderly patients with ESRD include:
► Life expectancy of such patients
► Effect of ESRD on life expectancy and quality of
life
► HD vs PD
► Timing of access placement

Effect of Age, Gender, and Diabetes on Excess

Death in ESRD. JASN 18:2125-2134, 2007

►All incident dialysis patients between January 1999-December 2003 in Rhone- Alpes region, France. ►3025 patients were
►All incident dialysis patients between
January 1999-December 2003 in Rhone-
Alpes region, France.
►3025 patients were analyzed.
►Age and gender standardized mortality ratio
(SMR) was computed in ESRD vs general
population of the region.
►Overall and by patient subgroups.
► Population 6 million. ► Rhône-Alpes is located in the east of France. The east of
► Population 6 million.
► Rhône-Alpes is located in
the east of France. The
east of the region contains
the western part of the
Alps. The highest peak is
Mont Blanc. The central
part of the region is taken
up with the valley of the
Rhône and the Saône. The
confluence of these two
rivers is at Lyon, the
capital of the region.

There are three kinds of lies: lies, damned lies, and statistics.” Benjamin Disraeli, Prime Minister of England end of 19 century.

► Standardized Mortality Ratio ► SMR = Observed Deaths / Expected Deaths ► Excess Deaths =
► Standardized Mortality Ratio
► SMR = Observed Deaths / Expected Deaths
► Excess Deaths = Observed Deaths - Expected Deaths
► Charlson Index contains 19 categories of comorbidity,
which are primarily defined using ICD-9-CM diagnoses
codes.
► Each category has an associated weight, which is based
on the adjusted risk of one-year mortality.
► The overall comorbidity score reflects the cumulative
increased likelihood of one-year mortality; the higher the
score, the more severe the burden of comorbidity.

Characteristics of study population.

► Total cohort 3025 patients. Survivlal Total 75-84 >85 % yrs 1 yr 82 69 59
► Total cohort 3025
patients.
Survivlal
Total
75-84
>85
%
yrs
1 yr
82
69
59
► Age 75-84: n=719;
>85: n=139
2 yr
70
50
39
► Gender ration (m/f) =
3 yr
62
37
23
1.7
► 75 % of pt >75 were
treated with HD.
4 yr
55
26
12
5 yr
48
18
9
SMR in ESRF versus GP of the same age and the same gender.
SMR in ESRF versus GP of the same age and the
same gender.
SMR in ESRF versus GP of the same age and the same gender.

Kaplan-Meier survival curves by age group and

standardized mortality ratios by age group.

Kaplan-Meier survival curves by age group and standardized mortality ratios by age group.

Octogenerians and nonagenarians starting dialysis

in the US. Ann Intern Med 146:177-183, 2007

► USRDS Standard Analysis Files from 1996 through 2003 for these analyses. ► Included all persons
► USRDS Standard Analysis Files from 1996
through 2003 for these analyses.
► Included all persons 65 years of age and older
who began dialysis between 1 January 1996 and
31 December 2003 (n=350,831).
► The focus of these analyses was the very elderly;
► Included patients 65 to 79 years of age (the
“young” elderly) in the analyses as a reference
group.
► Excluded patients initiating dialysis after a failed
kidney transplantation (n=4,693)

Incidence of dialysis initiation.

Incidence of dialysis initiation.

Trends in dialysis initiation.

1996-2003, 78,419 octogenarians and 5,577 nonagenarians initiated dialysis in the United States.

► 7,054 pts in 1996  13,577 pts in 2003: average annual increase 8.6%(2.3%) in 80-84
► 7,054 pts in 1996  13,577 pts in 2003: average annual increase
8.6%(2.3%) in 80-84 yrs and 11.9%(3.2%) > 85 yrs.
► Annual increase in dialysis initiation among patients 65-79 yrs was
3.5%(0%).
► Accounting for population growth, rates of dialysis initiation increased
by 57% among octogenarians and nonagenarians from 1996 to 2003.
► For persons older than 84 years of age, rates of dialysis initiation were
dramatically lower than other elderly age groups; this effect persisted
over time.

Survival.

Survival.

Survival.

► One year mortality rate for octogenarians and Age group, Median Average life survival, expectancy, yrs
► One year mortality rate for
octogenarians and
Age group,
Median
Average life
survival,
expectancy,
yrs
nonagenarians starting dialysis
was 46% and did not change
over the 7-year period.
mo
mo
65-79
25
?
► Associated clinical
characteristics: nonambulatory
status, low serum albumin
concentration, congestive heart
failure, and underweight were
most strongly associated with
death.
80-84
15
105
85-89
12
75
>90
8
57

Comparison and Survival of HD and PD in the

elderly. Seminars in Dialysis 15:2:98-102, 2002

► Inclusion: Initiated dialysis during the years 1995±1997, >67 yrs at the time of initiation. (N=89,193).
► Inclusion: Initiated dialysis during the years 1995±1997, >67 yrs at the
time of initiation. (N=89,193).
► Source: Medicare claims.
► Dialytic modality: Determined on day 90 of ESRD care, >60 days on
this modality.
► After excluding all pts with missing info: N=70,208; 6,695 (10%) on PD
and 63,513 (90%) on HD
► Interval Poisson regression was used to calculate adjusted death rates
and relative risks between the PD and HD populations.
► Analyses were adjusted for age, gender, race , geographic location (six
groups of renal networks), Charlson comorbidity index score, baseline
GFR, prior hospital days, incidence year (1995, 1996, 1997), and
primary cause of renal failure (diabetes, hypertension, GN, other).
► Separate analyses were performed for the diabetic and nondiabetic
populations.
Table 1.
Table 1.
Table 1.

Death rates per 1000 patient years

Relative risk of death.
Relative risk of death.

Interval death rates DM and non-DM.

Interval death rates DM and non-DM.
Interval relative risks (HD:PD) of death for Dm vs non-DM.
Interval relative risks (HD:PD) of death for Dm vs
non-DM.
Interval relative risks (HD:PD) of death for Dm vs non-DM.

The longer, the better?

► 12 month prospective cohort study of outcomes in 221 patients with ESRD, started on HD,
► 12 month prospective cohort study of outcomes in 221 patients with
ESRD, started on HD, age >70 yrs.
► Recruted from 4 hospital based dialysis units.
► Quality of life was assessed by interview at 90 days after initiation of
HD in new patients and at 5 months to 10.8 yrs in chronic patients.
► SF-36 physical component summary (PCS) and mental component
summary (MCS) scores were calculated;
► High scores indicate good quality of life.
► SF-36 scores were compared with UK general population norms for
people 70 years or over and US norms for adults aged 65–74 and 75
years or over.
Lancet 2000

Dismal rehabilitation in geriatric inner-city

hemodialysis patients. E. Freidman et al. JAMA 1994

► Cohort study of elderly patients who have end-stage renal disease. ► Current status was compared
► Cohort study of elderly patients who have end-stage renal
disease.
► Current status was compared with patient's recollection of
functional activity level 2 years before commencing
maintenance hemodialysis.
► Seven outpatient, hospital-affiliated and private
hemodialysis units in Brooklyn, NY.
► 104 patients aged 65 years or older who were receiving
maintenance hemodialysis for at least 6 months.
► Measured outcome: A score of 76 or greater on a modified
Karnofsky scale indicated independent function at a level
that permitted participation in activities beyond those
mandated by the hemodialysis regimen.

Karnofsky performance scale.

► 100% - normal, no complaints, no signs of disease ► 90% - capable of normal
► 100% - normal, no complaints, no signs of disease
► 90% - capable of normal activity, few symptoms or signs of disease
► 80% - normal activity with some difficulty, some symptoms or signs
► 70% - caring for self, not capable of normal activity or work
► 60% - requiring some help, can take care of most personal
requirements
► 50% - requires help often, requires frequent medical care
► 40% - disabled, requires special care and help
► 30% - severely disabled, hospital admission indicated but no risk of
death
► 20% - very ill, urgently requiring admission, requires supportive
measures or treatment
► 10% - moribund, rapidly progressive fatal disease processes
0% - death.

Results.

► Karnofsky score deteriorated to average of 66 compared with patients' recollection of a mean score
► Karnofsky score deteriorated to average of 66 compared with patients'
recollection of a mean score of 84 (P < .001) 2 years before initiation of
hemodialysis.
► Diabetic patients had a lower score than nondiabetic patients.
► Within the diabetic subset, severe debility constrained 71 patients
(68%) to limit all activity to their residence with the exception of travel
to and from their dialysis facility.
► 2 years prior to commencing dialytic therapy, 81 diabetic patients
(78%) had interests and activities that took them outside their homes
(P < .001).
► CONCLUSIONS: Maintenance hemodialysis does not return inner-city
elderly patients to their predialysis level of functioning. Few elderly,
diabetic hemodialysis patients conduct any substantive portion of their
lives outside their homes.
When to refer patients with chronic kidney disease for vascular access surgery: Should age be a
When to refer patients with chronic kidney disease
for vascular access surgery: Should age be a
consideration? KI 71:555-561,2007
► Retrospective cohort study among 11,290 non-dialysis patients with
aneGFR of 25 ml/min/1.73m2 based on 2000–2001 outpatient
creatinine measurements in the Department of Veterans Affairs.
► For each age group, the percentage of patients that had and had not
received a permanent access by 1 year after cohort entry, and the
percentage in each of these groups that died, started dialysis, or
survived without dialysis was established.
► Modeled the number of unnecessary procedures that would have
occurred in theoretical scenarios based on existing vascular access
guidelines.
► The mean eGFR was 17.7 ml/min/1.73m2 at cohort entry.
► Mean age of the patient cohort was 70 yrs.
► 25% (n=2870) of patients initiated dialysis within a year of cohort entry.
► Only 39% (n=1104) had undergone surgery to place a permanent
When to refer patients with chronic kidney disease for vascular access surgery: Should age be a

access beforehand.

When to refer patients with chronic kidney disease for vascular access surgery: Should age be a

Permanent vascular access surgeries by age group.

Permanent vascular access surgeries by age group. A Percent of all cohort patients who received pre-dialysis
A Percent of all cohort patients who received pre-dialysis permanent access by the end of follow-up.

A Percent of all cohort patients who received pre-dialysis permanent access by the end of follow-up. Estimates are provided with a 95% confidence interval.

A Percent of all cohort patients who received pre-dialysis permanent access by the end of follow-up.

B Percent of patients who initiated dialysis during follow-up that had undergone permanent access placement before initiation of dialysis. Estimates are provided with a 95%confidence interval.

Permanent vascular access surgeries by age group. A Percent of all cohort patients who received pre-dialysis

One year outcome by age group.

One year outcome by age group.

Ratio of unnecessary to necessary permanent access

surgeries at different theoretical referral eGFR thresholds by

age and length of follow-up.

a Referral threshold eGFR=25 b Referral threshold eGFR=20 c Referral threshold eGFR=15
a Referral threshold eGFR=25
b Referral threshold eGFR=20
c Referral threshold eGFR=15

Conclusion.

► Rates of initiation of dialysis in elderly is increasing: increase ckd prevalence, earlier initiation of
► Rates of initiation of dialysis in elderly is
increasing: increase ckd prevalence, earlier
initiation of dialysis, more liberal acceptance in
dialysis programs.
► Dialysis can significantly prolong life in elderly
population.
► Elderly seem to do better on HD vs PD.
► QOL: more studies needed.
► Access: when should avf/avg be placed in elderly
?