Transcript Chronic disease management in older people with

Chronic disease
management in older
people with advanced CKD
Shelagh O’Riordan
Consultant Geriatrician and BGS representative on recent NICE CKD
guidelines
What I will be talking about:
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The approach to CKD as a geriatrician
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Diagnosis and classification of CKD
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Anaemia

Bones

Acidosis

Heart failure
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Summary
Frailty and CKD

Frailty very common in CKD (more so
than those without)
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Functional impairment
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Cognitive impairment- even younger
patients with moderate CKD have
measurable cognitive impairment

Older people more influenced by
potential for side effects of
treatment than potential risk
reduction

Are renal physicians actually
geriatricians?

Are geriatricians actually partly renal
physicians?
Mrs A
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76 y o woman
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CKD stage 4, severe OA, hypertension, diabetes
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GFR 25-30, 2+ protein on urine dip, BP 145/90
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Difficulty getting out of chair, especially at the end of the day
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Family live nearby but has difficulty getting out of the house to be involved in
their lives

Codeine based analgesia cause severe constipation
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Asks if she can take NSAIDS for her knee pain
Do we have a different perspective?
Disease orientated approach
Person orientated approach
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Comprehensive geriatric assessment
(CGA)
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Increase ACEI for BP control as high
risk CVD and progression
Acknowledge conflicting priorities
with NSAID use


Assess knee pain likely not to be
related to kidneys
Consider other options eg therapy,
assistive devices, other analgesia


Use of NSAIDs likely to worsen
function
If really can’t cope without NSAIDS,
change ACEI to different
antihypertensive agents

Goal of treatment- what matters
most to patient, preserving
independence, planning for the
future

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History related to kidney functionoedema, BP etc. Assess progression
and CVD risk
Goal of treatment- preserve renal
function, reduce CVD risk
Diagnosis of kidney disease
The debate rages on……
Age calibrated classification
of CKD

Doesn’t take into account normal
aging

Incorrect labelling of older people
with CKD- overdiagnosis


40-50% of the population will
develop CKD in their lifetime!
Suggests a new classification for
older people starting at eGFR of 45
Continue with current
classification

CKD is commoner in older people- so
is hypertentsion, diabetes,
hyperlipaemia- all increase risk of
CVD

Not a consequence of normal agingwide variation in eGFR and protein
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Low eGFR and high protein excretion
related to higher mortality
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Age calibration will be too
complicated
Did NICE CKD 2014 tackle this issue?
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Use creatinine based equation CKD-EPI
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If eGFRcreatinine 45-59 and no other signs of CKD, do an eGFRcystatinC
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Do not diagnose CKD in people with:
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•an eGFRcreatinine of 45–59 ml/min/1.73 m2 and
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•an eGFRcystatinC of more than 60 ml/min/1.73 m2 and
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•no other marker of kidney disease
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Significant proportion of older people with very low risk of problems from CKD
removed from the “CKD List”
Updated categories of CKD
Anaemia in CKD
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Managing renal anaemia improves QOL

May have a role in treatment even for
very frail patients
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Investigate if Hb<110g/L or symptomatic
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Diagnose iron deficiency and treat first
but if target Hb not reached after 6M
consider referral
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IV iron to keep %hypochromic red cells
<6%
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Epo to keep Hb 100-120g/L
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Trial of treatment- stop if not improving
symptoms.
Renal bone disease and osteoporosis
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Significant increase in hip fracture
if eGFR<60
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In men 50-74y 3x increase CKD in
those with hip fracture than those
without
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High risk hip fracture if on dialysis
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Difficult to treat
Treatment options for osteoporosis in
CKD
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Diagnose vitamin D deficiency in
same way you normally would
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Use 1-alpha hydroxylated vitamin D
if eGFR <30mmol/l and monitor
calcium
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Use oral bisphosphonates if eGFR
>30mmol/l
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Only use IV zoledronic acid if eGFR
>35ml/min/m2 and clinically
indicated
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Can use denosumab if eGFR <30
but not if on dialysis or eGFR<15high risk of hypocalcaemia
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Don’t forget your best treatment
might be falls prevention!!
Should we treat metabolic acidosis in
older people?
Advantages


Metabolic acidosis common in
advanced CKD
Leads to muscle weakness,
fractures and CVD
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Evidence of reduction in disease
progression
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Evidence of improved nutrition
Disadvantages
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Bulky, difficult to take tablets- 3/d
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Increase sodium load- fluid
retention, increase BP
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GI side effects
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No evidence improves quality of
life
Fluid overload and CKD
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Always difficult
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Symptom control versus kidney
function?
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Poor long term prognosis
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What about other drugs towards
end of life?
Mr D
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82 year old gentleman: short of breath for 2 weeks, gradually increasing, high INR
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Background: ICM with biventricular PPM, IHD – PCI to LAD, AF, stage 3B CKD
(baseline eGFR 32), gout, BPH, diabetes
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Medications: Aspirin 75mg od, Clopidogrel 75mg od, Warfarin, Allopurinol 100mg
od, Lisinopril 5mg od, Digoxin 250mcg od, Finasteride 5mg od, Atorvastatin 40mg
od, Furosemide 40mg bd, Gliclazide 40mg bd, codydramol 2 QDS
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Recent acute gout: treated with 5/7 Naproxen 500mg bd
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On admission: heart rate 118/min, BP 93/63, fluid overloaded, drowsy
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Bloods: Hb 112, Na 132, K 5.7, creatinine 287 (eGFR 19), ALT 488, ALP 316, CRP 20,
INR 13.5, Glucose 4.5
Management plan
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Stop ACEI- more effect on kidney function than diuretics
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Stop warfarin, aspirin and clopidogrel
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Check digoxin level- stop digoxin
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Stop codeine based analgesia
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Stop gliclazide
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High dose IV frusemide- started at 80mg IV am and lunchtime
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Daily weights- much easier than input-output charts! Fluid restrict
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SBP consistently 90-100mmHg
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Continued deterioration in renal function: Cr 287 – 352 in 2 days- diuretic dose increased to
120mg am, 80mg lunchtime
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Slowly started to lose weight
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Renal function started to improve and back to near normal by day 7
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Symptomatically much improved
Points to remember
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High dose diuretic better for symptom control than ACEI
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Renal function and blood pressure may improve if off loaded
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Diabetes drugs especially sulphonylureas need reviewing- prolonged
hypoglycaemia
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How long to fluid restrict?
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Consider using palliative care medications and referral early rather than late
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Which opiate is best in CKD?
What message to take home in later
stages CKD- the geriatricians opinion!
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Don’t make renal function and disease progression your main goal
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All the skills of the geriatrician are required to get it right
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New ways to diagnose and classify CKD- but these won’t affect acute care
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Advised you on current management of some of the acute presentationsfractures, anaemia, CCF
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Await answers to trials on treatment of acidosis
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Work together with the primary care team, renal team and palliative team to
provide best care for your patient