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| REVIEW ARTICLE |
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| Year : 2016 | Volume
: 3
| Issue : 3 | Page : 71-73 |
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Prevention, Diagnosis, and Treatment of Chronic Kidney Diseases in Older Adults: Current Status and Prospective
Guangyan Cai, Xiangmei Chen
Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, PR China
| Date of Web Publication | 4-Aug-2016 |
Correspondence Address:
Xiangmei Chen
Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing
PR China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2394-2916.187785
The elderly are at high risk of chronic kidney disease, who has become a major population in the newly admission to dialysis treatment. So the elderly will be the focus of CKD prevention task in future. At present, challenges still remain in the diagnosis and treatment of CKD in the elderly: there is no unified criteria for CKD diagnosis in the elderly, un-settled treatment target of CKD complications in the elderly; complicated theraputic strategies in the elderly ESRD patients. We particularly stress the importance of patient-centered, instead of disease-oriented, individualized treatment in the prevention and treatment of CKD in the elderly.
Keywords: Chronic kidney diseases, elderly, end stage renal disease
How to cite this article:
Cai G, Chen X. Prevention, Diagnosis, and Treatment of Chronic Kidney Diseases in Older Adults: Current Status and Prospective. J Integr Nephrol Androl 2016;3:71-3 |
How to cite this URL:
Cai G, Chen X. Prevention, Diagnosis, and Treatment of Chronic Kidney Diseases in Older Adults: Current Status and Prospective. J Integr Nephrol Androl [serial online] 2016 [cited 2023 May 28];3:71-3. Available from: http://www.journal-ina.com/text.asp?2016/3/3/71/187785 |
| Introduction | |  |
According to the United Nations, an aging society is defined as older population over 60-year-old takes up 10% of the total population or over 65-year-old takes up 7% (the United Nations, https://www.un.org/development/desa/ageing/). China has been an aging society since 1999 (National Bureau of Statistics of the People's Republic of China, http://www.stats.gov.cn). Body aging can cause structural and functional alterations in the kidney, one of the target organs of aging. Prevalence of chronic kidney disease (CKD) increases with age, being higher among older population than among the young. In the general population, the prevalence of CKD is approximately 10-13%, [1],[2] but the number can be as high as 30-50% among older adults [3] Similar results are observed in different populations and countries. Older patients take up nearly half of the incident dialysis patients in economically developed areas in China, and older adults are the major victims of end-stage renal disease (ESRD). CKD and aging is the theme of 2014 World Kidney Day, it is aimed to increase the awareness of CKDs and aging. Correcting risk factors, reducing CKD prevalence in older people, delaying the progression of CKD to ESRD, and increasing treating effectiveness of ESRD are the important tasks in CKD prevention and treatment.
| Characteristics of chronic kidney diseases in older adults | | |
Aging is an important affecting factor in the progression of kidney diseases to ESRD. An aging kidney is vulnerable to various stressors due to its structural and functional alterations. Approximately, only one-third of older kidneys that suffer from acute injuries get full recovery, a situation that is very different from acute injuries in the young. [4] Acute injury in older kidney tends to accumulate and progress, leading to a higher risk of CKD in older patients. CKD in older adults is characterized by a decrease in estimated glomerular filtration rate (eGFR), whereas proteinuria is not overt. Decrease of eGFR and increase of albuminuria are the important mortality risk factors in CKD patients. All-cause mortality risk is more than 10 times higher in older patients than in younger patients, after adjusting for eGFR and albuminuria. Moreover, glomerular disease spectrum of older patients is different from younger patients. In older patients, secondary glomerular diseases represented by diabetic nephropathy, ischemic renal disease, myeloma nephropathy, and renal amyloidosis are significantly increased, while membranous nephropathy and crescent nephropathy are increased as primary kidney diseases. [5] Another character of CKD in older adults is that the patients are usually complexed with multiple underlying diseases, for example, diabetes, hypertension, congestive heart failure, and urinary obstruction, thus predisposing older patients to medication (antihypertensive, diuretics, contrast medium, antibiotics, and nonsteroidal anti-inflammatory drugs [NSAIDs]) and operative treatments (cardio and vascular surgery). Medication and surgery further increase the risk of renal injury in older patients. Both clinical and preclinical research demonstrate that given identical stressors (e.g., ischemia-hypoxia, inflammation, and nephrotoxic medication), older kidney reacts much negatively than younger kidney, and it suffers from a much higher A on C risk. Thus, older kidney requires active prevention and close monitoring.
| Current hurdles in chronic kidney disease in older adults | | |
It should be noted that problems exist in the diagnosis and treatment of CKDs in older patients: (1) There is no diagnostic criteria regarding CKDs in older patients. Estimation formula studies are scarce, and the few existing formulas underestimate the actual GFR for about 15-25% on an average. Therefore, it is still on dispute whether taking a GFR <60 mL/min/1.73 m 2 calculated by the existing formula as the diagnostic setting point for CKD in older adults is appropriate. [6] Older patients with CKD suffers from a higher risk to death, myocardial infarction, and stroke than the risk of progression to ESRD. (2) There is not yet a target for treating complications of CKD in older patients. Many international guidelines for kidney diseases do not explicitly explain CKD in older patients due to a lack of evidence-based research. This is a major obstacle for clinical decision-making. Treating the target of anemia, hypertension, mineral metabolism, and nutrition in CKD in older patients should be independent of that in younger patients. For example, the eighth report of the Joint National Committee on American Prevention, Detection, Evaluation, and Treatment of Hypertension (JNC8) sets a hypertension treatment target of <150/90 mmHg for patients over 60-year-old. [7] However, older patients, especially the extremely old often complicate arteriosclerosis and decreased vascular compliance, therefore prevention of excess lowering of diastolic blood pressure is necessary to protect the key organs from blood perfusion dysfunction. Based on the clinical guidelines, treatment of hypertension in older CKD patients should also be individualized, taking age, population, GFR, and complications into account to make an integrative decision on the treating target. Benefit and safety data concerning angiotensin-converting enzyme and/or angiotensin receptor blocker application in older CKD patients who have subtle proteinuria are still lacking because of the absence of reliable evidence from clinical trial. [8] If an older patient is complicated with hypovolemia or excess use of diuretics, and at the same time suffers from the left heart failure and renal artery stenosis, using renin-angiotensin system inhibitors combined with NSAIDs can increase the risk of renal injury. (3) Among nondialysis population, the treating principle for older and younger CKD patients is more or less the same. Clinical decision-making is made difficult mainly because of complications and thereafter intervention targets. As an example, mineral and bone disorder in CKD (CKD-MBD) is presented with both the bone diseases caused by secondary hyperparathyroidism and osteoporosis. Medication to a patient with CKD-MBD needs to balance the two aspects. [9] Metabolism of medication is slower in older patients, therefore it is preferable to begin therapy with a small dose, then gradually increase the dose until it is effective. Adverse effect needs to be closely watched. (4) Treatment to ESRD in older patients needs a trade-off evaluation. Due to complications and a shorter life expectancy, it is important to evaluate older patients with ESRD whether or not to start dialysis. [10] Older ESRD patients are gradually shifting to dialysis in economically developed countries in the world. Old age is no longer a contraindication for dialysis. Even though life expectancy is shorter in older patients, expected dialysis age is not different from younger patients. Old age is not a contraindication for kidney transplant, if other requirements are met. Improvement of life quality is always the priority, no matter which kind of renal replacement treatment is chosen. Evaluation of organ function, prognosis, cognition, social support, treatment burden, vision, hearing, and nutrition is a necessary part to an accurate evaluation of life quality. Measures such as cardiovascular events reduction, infection control, nutrition improvement, and dialysis adequacy will contribute to the better survival of older ESRD patients.
An aging population brings about new challenges for the prevention and treatment of CKD in China: There is not yet a diagnostic criteria of CKD in older adults; CKD in older patients is caused by different primary diseases than younger patients; older CKD patients are complicated with more underlying diseases; there is not yet a treatment target for older CKD patients. A therapeutic regimen calls for the integrative weighing and discussion among doctor, patient, family, and community. For older CKD patients, we emphasize on patient-centered individualized therapy rather than a disease-oriented management.
Acknowledgments
This study was supported by the Twelfth Five-Year National Key Technology R and D Program (2011BAI10B00, 2013BAI09B05, 2015BAI12B06) and the 973 program (2013CB530800).
Financial support and sponsorship
This study was supported by the Twelfth Five-Year National Key Technology R and D Program (2011BAI10B00, 2013BAI09B05, 2015BAI12B06) and the 973 program (2013CB530800).
Conflicts of interest
There are no conflicts of interest.
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