Survival of chronic hemodialysis patients over 80 years of age

Branka Sladoje-Martinovic, Ivana Mikolasevic, Ivan Bubic, Sanjin Racki, Lidija OrlicDepartment of Nephrology and Dialysis, Division of Internal Medicine, University Hospital Center Rijeka, Rijeka, CroatiaBackground/aim: The number of elderly patients with chronic kidney disease (CKD) stage 5 management with hemodialysis (HD) is steadily increasing. Therefore we analyzed the number of new CKD patients ≥80 years managed with HD and their survival through the study period. We aimed also, to identify which of several key variables might be independently associated with survival in this very elderly population of patients.Patients and methods: This was a single-center, retrospective cohort study that took place during the period from January 1987 to September 2012. The study consisted of 78 (50 male and 28 women) very elderly patients (≥80 years of age); the mean age at which HD was initiated was 83.2±2.5 years. Survival and factors associated with mortality were studied. Survival was defined as the time from start of HD treatment to death (or end of study, if still alive).Results: In the period from 1987 to 2002, patients ≥80 years of age were only sporadically treated with HD, but since 2003, the number of new patients has been steadily increasing. The mean survival for our group of patients was 25.1±22.4 months (range 1–115 months). Furthermore, 30.8% patients survived <12 months, 29.5% patients survived 12–24 months, 30.8% patients survived 24–60 months, and 9% patients survived >60 months on HD treatment. Older patients were less likely to have diabetes, and primary renal disease did not influence survival. Patients with high C-reactive protein levels and poor nutritional status, as well as those who did not have pre-HD nephrology care and those that had a catheter as vascular access for HD had poor survival. In about half of our patients, the cause of death was cardiovascular disease.Conclusion: Among patients who were ≥80 years of age at the start of HD treatment, those who received pre-HD nephrology care that followed a planned management pathway, those who had a good nutritional status, and those with an arteriovenous fistula as vascular access for HD at the time of HD initiation had a better survival.Keywords: chronic kidney disease, elderly patients, pre-HD nephrology care, nutritional status, arteriovenous fistul

Nonalcoholic fatty liver disease (NAFLD) – a new factor that interplays between inflammation, malnutrition, and atherosclerosis in elderly hemodialysis patients

Ivana Mikolasevic,1 Vesna Lukenda,2 Sanjin Racki,1 Sandra Milic,3 Branka Sladoje-Martinovic,1 Lidija Orlic1 1Department of Nephrology, Dialysis and Transplantation, Rijeka University Hospital Center, Rijeka, Croatia; 2Department of Internal Medicine, Dr Josip Bencevic General Hospital, Slavonski Brod, Croatia; 3Department of Gastroenterology, Rijeka University Hospital Center, Rijeka, Croatia Background/aim: In the past decade, in most regions of the world, an increasing number of adults aged 65 years and older were started on renal replacement therapy each year. In contrast to the general population for whom overnutrition or obesity is associated with increased cardiovascular risk, for patients who are maintained on hemodialysis (HD), malnutrition and malnutrition-inflammation complex syndrome are associated with poor outcome. In recent years, nonalcoholic fatty liver disease (NAFLD) has been considered to be the liver manifestation of metabolic syndrome, and the development of NAFLD is strongly associated with all components of metabolic syndrome (arterial hypertension, dyslipidemia, obesity, and diabetes mellitus type 2) in the general population. The primary end point of this study was to determine the patient’s survival in relation to nutritional and inflammatory state and the presence or absence of NAFLD. The secondary end point of this analysis was the association among NAFLD and various clinical and laboratory data, with the nutritional and inflammatory state of our elderly HD patients. Methods: Using a single-center, prospective, cohort study design, we followed the progress of 76 patients who were ≥65 years and treated with chronic HD for at least 6 months, at the Department of Nephrology, Dialysis and Transplantation. All patients were followed for a minimum of 18 months or until death. Survival was defined as the time from study initiation to death (or end of study, if still alive).Results: The main findings of our study were a remarkable positive correlation between NAFLD and high-sensitivity C-reactive protein (hs-CRP) (r=0.659; P<0.0001) and consequent negative correlation with the nutritional parameter, serum albumin (r=-0.321; P=0.004). Interestingly, we showed that in contrast to the general population, where NAFLD is associated with obesity, in the present study, there was no statistically significant association between NAFLD and overnutrition in elderly HD patients. Furthermore, the presence of NAFLD, low serum albumin levels, and high hs-CRP were strong predictors of poor outcome in our elderly HD patients. Conclusion: Our results indicated that NAFLD probably interplays between inflammation, malnutrition, and atherosclerosis in elderly HD patients. NAFLD could be a new factor that contributes to type 2 malnutrition in elderly HD patients, who may be amenable to adequate nutritional and HD support. Keywords: cardiovascular risk, serum albumin, high-sensitivity C-reactive protein (hs-CRP

Treatment of degenerative mitral regurgitation in elderly patients

Advanced age is a common contraindication for cardiac surgery, particularly in high-risk patients with comorbidities, such as pulmonary and renal impairment, associated coronary artery disease, and neurological disorders. In elderly patients with degenerative mitral regurgitation who are not eligible for conventional surgical valve repair or replacement, percutaneous valve repair is emerging as a viable alternative therapeutic option. Nonsurgical and minimally invasive therapies for degenerative mitral regurgitation are of particular value in this subset of patients, because these interventions are associated with reduced perioperative mortality, clinical improvement, and faster recovery than is possible with surgical procedures. However, given that surgery remains the gold-standard treatment and should still be considered an option regardless of a patient's age, transcatheter mitral valve repair should be performed only in candidates who will gain the most benefit from it. The balance between the risks and benefits, and the value versus the futility of procedures to treat degenerative mitral regurgitation in elderly patients should be assessed by a specialized multidisciplinary care team. In this Review, we discuss the treatment options and indications for degenerative mitral regurgitation in elderly patients

Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters

PURPOSE:The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD. METHODS:A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics. RESULTS:Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk. CONCLUSION:Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making