Proceedings From the Symposium on Kidney Disease in Older People: Royal Society of Medicine, London, January 19, 2017

People are living longer. On the whole, they have healthier lives and many of the problems previously seen at a younger age now appear in their later years. Kidneys, like other organs, age, and kidney disease in the aged is a prime example. In the United Kingdom, as in other developed countries, the prevalence of end stage kidney disease is highest in the 70- to 79-year-old age group. There are many older people who require renal replacement and are now considered for dialysis. While older patients with end-stage renal disease invariably aspire for a better quality of life, this needs a specialized approach and management. In January 2017, the Royal Society of Medicine held a seminar in London on “Kidney Disease in Older People” with presentations from a multidisciplinary body of experts speaking on various aspects of kidney problems in this age group and its management. The objectives were to increase awareness and improve the understanding of nephrology in the context of geriatric medicine but also geriatrics in its interface with nephrology, especially in the area of chronic kidney disease

Cognitive impairment and patient reported outcomes in advanced kidney disease

Shared decision making is now an integral part of renal practice. Quality of life is therefore an important consideration, especially for older patients. This thesis provides insight into the influence of dialysis modality on quality of life in older people with advanced kidney disease. It also explores the relationship between cognitive impairment and dialysis. Firstly, quality of life measures were compared between older patients on assisted peritoneal dialysis and haemodialysis. Patients on assisted peritoneal dialysis were matched to haemodialysis patients by baseline characteristics. Quality of life assessments were carried out quarterly for 2 years. Following multivariate analyses, there was no consistent difference in quality of life between patients on haemodialysis and assisted peritoneal dialysis. The second study assesses the influence of dialysis on cognition and patient reported outcome measures in patients with advanced kidney disease. Patients on haemodialysis, peritoneal dialysis or with chronic kidney disease (eGFR < 30ml/min) patients were recruited. Study participants were assessed 4 monthly for up to 2 years. Mixed model analysis showed that cognitive function declined faster in dialysis patients compared with non-dialysis patients with chronic kidney disease. In the dialysis cohort, executive function was better preserved in patients on peritoneal dialysis compared with haemodialysis patients. Dialysis did not consistently influence trends in patient reported outcome measures during follow up. Finally, the relationship between cognition and decision making capacity was explored in a small pilot of renal patients. Cognition and decision making capacity were assessed by the Montreal Cognitive Assessment and Macarthur Competence Assessment tools respectively. Patients with lower cognitive scores tended to have lower capacity assessment scores, albeit without reaching statistical significance. In older patients with advanced kidney disease, risk factors other than dialysis modality, influence quality of life. Cognitive decline, one such risk factor, may accelerate with dialysis depending on modality. It may also affect decision making. These findings highlight the need to screen for geriatric syndromes in older patients with renal disease.Open Acces

The prevalence and impact of falls in elderly dialysis patients Frail elderly Patient Outcomes on Dialysis (FEPOD) study

Background: As the numbers of older patients on dialysis rise, geriatric problems such as falling become more prevalent. We aimed to assess the prevalence of falls and the impact on mortality and quality of life in frail elderly patients on assisted PD (aPD) and hemodialysis (HD) from the FEPOD Study.Methods: Data on falls and quality of life were collected with questionnaires at baseline and every six months during 2-year follow-up. Multiple regression analysis was used to evaluate factors associated with falls. Additionally, we performed a review of literature concerning the relation between falls and poor outcome.Results: Baseline fall data were available for 203 patients and follow-up data for 114 patients. Dialysis modality was equally distributed (49% HD and 51% aPD). Mean (SD) age was 75 +/- 7 years. Fall rate was 1.00 falls/ patient year, comparable in HD and aPD. Falls led to fear of falling, resulting in less activities in 68% vs 42% (p &lt;0.01) and leaving the house less in 59% vs 31% (p &lt;0.01) of patients. Patients with diabetes mellitus were twice as likely to report falls at baseline (OR 1.91 [95%CI 1.00-3.63], p = 0.05) and falls at baseline were associated with falls during follow-up (OR 2.53 [95%CI 1.06-6.04] p = 0.03). Literature revealed frailty was a strong risk factor for falling and falling results in a higher mortality and hospitalization rate.Conclusion: Falls were frequent in older dialysis patients and have a negative impact on quality of life. Fall incidence is comparable between aPD and HD.</p

Quality of Life and Physical Function in Older Patients on Dialysis : A Comparison of Assisted Peritoneal Dialysis with Hemodialysis

Copyright © 2016 by the American Society of Nephrology.BACKGROUND AND OBJECTIVES: In-center hemodialysis (HD) is often the default dialysis modality for older patients. Few centers use assisted peritoneal dialysis (PD), which enables treatment at home. This observational study compared quality of life (QoL) and physical function between older patients on assisted PD and HD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients on assisted PD who were >60 years old and on dialysis for >3 months were recruited and matched to patients on HD (needing hospital transport) by age, sex, diabetes, dialysis vintage, ethnicity, and index of deprivation. Frailty was assessed using the Clinical Frailty Scale. QoL assessments included Hospital Anxiety and Depression Scale (HADS), Short Form-12, Palliative Outcomes Symptom Scale (renal), Illness Intrusiveness Rating Scale, and Renal Treatment Satisfaction Questionnaire (RTSQ). Physical function was evaluated by Barthel Score and timed up and go test. RESULTS: In total, 251 patients (129 PD and 122 HD) were recruited. In unadjusted analysis, patients on assisted PD had a higher prevalence of possible depression (HADS>8; PD=38.8%; HD=23.8%; P=0.05) and higher HADS depression score (median: PD=6; HD=5; P=0.05) but higher RTSQ scores (median: PD=55; HD=51; P<0.01). In a generalized linear regression model adjusting for age, sex, comorbidity, dialysis vintage, and frailty, assisted PD continued to be associated with higher RTSQ scores (P=0.04) but not with other QoL measures. CONCLUSIONS: There are no differences in measures of QoL and physical function between older patients on assisted PD and comparable patients on HD, except for treatment satisfaction, which is higher in patients on PD. Assisted PD should be considered as an alternative to HD for older patients, allowing them to make their preferred choices.Peer reviewe

Novel Colorimetric and Light Scatter Methods to Identify and Manage Peritoneal Dialysis-Associated Peritonitis at the Point-of-Care

Introduction: Peritoneal dialysis (PD)-related peritonitis (PDRP) is a common cause of transfer to hemodialysis, patient morbidity, and is a risk factor for mortality. Associated patient anxiety can deter selection of PD for renal replacement therapy. Diagnosis relies on hospital laboratory tests; however, this might be achieved earlier if such information was available at the point-of-care (POC), thereby significantly improving outcomes. The presence of culturable microbes and the concentration of leukocytes in effluent both aid peritonitis diagnosis, as specified in the International Society for Peritoneal Dialysis (ISPD) diagnostic guidelines. Here, we report the development of 2 new methods providing such information in simple POC tests. Methods: One approach uses a tetrazolium-based chemical reporting system, primarily focused on detecting bacterial contamination and associated vancomycin-sensitivity. The second approach uses a novel forward light-scatter device (QuickCheck) to provide an instant quantitative cell count directly from PD patient effluent. Results: The tetrazolium approach detected and correctly distinguished laboratory isolates, taking 10 hours to provide non-quantitative results. We compared the technical performance of the light scatter leukocyte counting approach with spectrophotometry, hemocytometer counting and flow cytometry (Sysmex) using patient effluent samples. QuickCheck had high accuracy (94%) and was the most precise (coefficient of variation &lt;4%), showing minimal bias, overall performing similarly to flow cytometry. Conclusion: These complementary new approaches provide a simple means to obtain information to assist diagnosis at the POC. The first provides antibiotic sensitivity following 10 hours incubation, whereas the second optical approach (QuickCheck), provides instant accurate total leukocyte count.</p

Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR<45 mL/min/1.73 m2): a summary document from the European Renal Best Practice Group.

The population of patients with moderate and severe CKD is growing. Frail and older patients comprise an increasing proportion. Many studies still exclude this group, so the evidence base is limited. In 2013 the advisory board of ERBP initiated, in collaboration with European Union of Geriatric Medicine Societies (EUGMS), the development of a guideline on the management of older patients with CKD stage 3b or higher (eGFR >45 mL/min/1.73 m2). The full guideline has recently been published and is freely available online and on the website of ERBP (www.european-renal-best-practice.org). This paper summarises main recommendations of the guideline and their underlying rationales