1. Renal replacement therapy and the elderly. Misha Kotlov, MD July 10, 2007

2. Demographics. ► 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.

3. Issues at hand. ► 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

4. 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 analyzed. ► Age and gender standardized mortality ratio (SMR) was computed in ESRD vs general population of the region. ► Overall and by patient subgroups.

5. ► 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.

6. “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 = 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.

7. Characteristics of study population. ► Total cohort 3025 patients. ► Age 75-84: n=719; >85: n=139 ► Gender ration (m/f) = 1.7 ► 75 % of pt >75 were treated with HD. Survivlal % Total 75-84 yrs >85 1 yr 826959 2 yr 705039 3 yr 623723 4 yr 552612 5 yr 48189

8. SMR in ESRF versus GP of the same age and the same gender.

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

10. 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 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)

11. Incidence of dialysis initiation.

12. 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 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.

13. Survival.

14. Survival. ► ► One year mortality rate for octogenarians and nonagenarians starting dialysis was 46% and did not change over the 7-year period. ► ► Associated clinical characteristics: nonambulatory status, low serum albumin concentration, congestive heart failure, and underweight were most strongly associated with death. Age group, yrs Median survival, mo Average life expectancy, mo 65-7925? 80-8415105 85-891275 >90857

15. 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). ► ► 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.

16. Table 1.

17. Relative risk of death. Death rates per 1000 patient years

18. Interval death rates DM and non-DM.

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

20. The longer, the better? ► 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

22. 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 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.

23. Karnofsky performance scale. ► 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.

24. Results. ► 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.

25. 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 access beforehand.

26. Permanent vascular access surgeries by age group. 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. 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.

27. One year outcome by age group.

28. 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

29. Conclusion. ► 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 ?