1. THE TWO FACES OF
GERIATRIC CKD
Joel M. Topf, MD

10. Modeled laboratory reporting of creatinine versus
MDRD and its effect on death, dialysis and cost
effectiveness

11. 10,000 patients 60+ years old
getting yearly evaluations for
up to 18 years.
They ran the simulation 1,000
times
Modeled laboratory reporting of creatinine versus
MDRD and its effect on death, dialysis and cost
effectiveness

12. eGFR performed better than a simple creatinine:
29 cases of ESRD prevented
13 premature deaths avoided

13. eGFR performed better than a simple creatinine:
29 cases of ESRD prevented
13 premature deaths avoided
However, it also over diagnosed chronic kidney
disease:
11,348 times

14. eGFR performed better than a simple creatinine:
29 cases of ESRD prevented
13 premature deaths avoided
However, it also over diagnosed chronic kidney
disease:
11,348 times
The conclusion was that the high rate of false
positives with eGFR reporting prevented the test
from being cost effective.

15. eGFR performed better than a simple creatinine:
29 cases of ESRD prevented
13 premature deaths avoided
However, it also over diagnosed chronic kidney
disease:
11,348 times
The conclusion was that the high rate of false
positives with eGFR reporting prevented the test
from being cost effective.

16. 2002 National Kidney Foundation Spring Clinical Meeting
K/DOQI Clinical Practice Guidelines
for Chronic Kidney Disease:
Evaluation, Classification, and Stratification

17. GFR = 170 x sCr -0.999 x Urea -0.170 x Alb +0.318 x Age -0.176 x (0.762 if female) x
(1.18 if African-American)

18. GFR=186 x sCr -1.154 x Age -0.203 x (0.742 if female) x (1.212 African-American)
Levey AS, Greene T, Kusek JW, Beck GJ: A simplified equation to predict glomerular filtration
rate from serum creatinine. J Am Soc Nephrol 11:A0828, 2000 (abstract)

19. Go A, Et al. NEJM 2004; 351: 1296-1305.

20. Go A, Et al. NEJM 2004; 351: 1296-1305.

21. Go A, Et al. NEJM 2004; 351: 1296-1305.

22. Go A, Et al. NEJM 2004; 351: 1296-1305.

23. JAMA. 2007 Nov 7;298(17):2038-47.

24. 26.3 million Americans
with CKD
50% of Americans over
69 have CKD
JAMA. 2007 Nov 7;298(17):2038-47.

29. half of the people
over 70 have CKD
What happens to these patients?

31. Tromso, Norway, population: 58,000

32. Tromso, Norway, population: 58,000

33. Tromso, Norway, population: 58,000
One hospital. One clinical lab.

34. Tromso, Norway, population: 58,000
One hospital. One clinical lab.
Next nearest lab, 180 miles away

35. 10 year study: Jan 1994 through Dec 2003

36. 10 year study: Jan 1994 through Dec 2003
58,086 people in the city

37. 10 year study: Jan 1994 through Dec 2003
58,086 people in the city
6,863 had an eGFR 30-59

38. 10 year study: Jan 1994 through Dec 2003
58,086 people in the city
3,074 (5%) had 2nd eGFR 30-59 three
mo. after the initial measurement

39. Patients outcomes. Mean follow-up: 50 months
2%
31% 66%
No Endpoint
Died
Renal Failure
Eriksen, Ingebretsen. The progression of CKD: a 10-yr population-based study. Kidney Int (2006) vol. 69 (2) p. 375-82

40. 1.00 Renal Failure Death
0.84
0.75
0.49
0.50
0.25 0.17
0.07 0.04 0.03
0
<70 70-79 >79
Age
C U M U L AT I V E 1 0 Y E A R I N C I D E N C E O F R E N A L
FA I L U R E A N D D E AT H I N C K D S TA G E 3
Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82

41. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82

42. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82

43. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82

44. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82

45. 2.0
1.60
mL/min per year 1.5
1.04
1.0
0.50
0.5
0
<70 70-79 >79
LOSS OF GFR BY AGE
Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82

46. less renal failure faster progression

47. Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82

48. Even though older people
were less likely to have
stable renal function
and had faster loss of
renal function they had a
lower risk of
renal failure
Eriksen, Ingebretsen. Kidney Int (2006) vol. 69 (2) p. 375-82

50. All patients with a eGFR ≤60 in the year following
October 1, 2000 who had an additional eGFR ≤ 60 in
the previous 3 months.
Creatinine and outcomes were tracked for up to four
years (until 9/30/04).
O'Hare et al. Age affects outcomes in chronic kidney disease. J Am Soc Nephrol (2007) vol. 18 (10) pp. 2758-65

51. 209,622 veterans with CKD 3, 4 or 5.
Mean age 73, 47% over 75
97% male
Allen Park Veterans Administration Hospital, 1949

52. Incidence of death per 100 person-years
30
CKD 4 25.4
25
CKD 3b
20 CKD 3a
16.5
15.4
15 13.3
11.7
9.9
10 7.6 7.1 6.9
6.1 5.6
4.4 4.3
5 2.9 2.8 2.9
1.8
0
18 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 to 100
Age category

53. Incidence of dialysis or transplant per 100 person-years
25
20.3
20 CKD 4
17.2
15.0 CKD 3b
15
CKD 3a
9.3
10
6.2 6.3
5 3.6
2.2 2.7
1.3
0.3 0.6 0.3 0.2 0.6
0.1 0.2
0.1
0
18 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 to 100
Age category

57. CKD 4

58. • preparation for dialysis
CKD 4 •
•
dialysis access surgery
pre-emptive transplantation

59. The geriatric CKD patient
is just an innocent
bystander in the growing
pains of defining and
classifying CKD.

60. Go A, Et al. NEJM 2004; 351: 1296-1305.

65. incidence
0-19
20-44
75+ 1% 13%
26%
incidence 65-74
45-64
38%
23%

66. 28,007 patients 75+ initiated dialysis in 2006

67. 75+ 0-19
16% 1% 20-44
19%
65-74
prevalence 20%
45-64
44%

68. 78,126 patients 75+ patients are on dialysis in 2006
dw

69. The geriatric CKD patient
is just an innocent
bystander in the growing
pains of defining and
classifying CKD.

70. Geriatric CKD patients
have a higher risk of dying
than progressing to
dialysis but they still
represent the age group
with the highest incidence
and second highest
prevalence of ESRD.

72. 2%
31% 66%
No Endpoint Died
Renal Failure

73. 2%
31% 66%
No Endpoint Died
Renal Failure

74. 2%
31% 66%
No Endpoint Died
Renal Failure

75. So they’re on dialysis.
How do they do?

76. Hospitalization
2.5
Admissions per patient year
2.20
2.2 2.09 2.08
2.07
1.98 1.99 1.98 2.01
1.94 1.95
1.9
1.6
1.3
1.0
All 20-44 45-64 65-74 75+
All-cause 1996 All-cause 2006

77. ESRD Population U.S. Population
80
Remaining Lifetime (years)
60
40
20
0
14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 89
Age

78. Fraction Of Predicted Lifespan Provided By Dialysis
50%
40%
30%
20%
10%
0%
0-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84

79. 360
Mortality (deaths per 1000 patient years) 300
240
180
120
60
0
<20 20-44 45-64 65+
ESRD Transplant General population

80. So they’re on dialysis.
How do they do?

81. So they’re on dialysis.
Pretty well.

82. Should we be dialyzing
these patients?

83. In previous analysis the patients
were compared to younger patients
or patients without kidney disease
This cannot answer the question:
To dialyze or
not to dialyze

85. 112 patients No diabetes, active
cancer, nephrotic range
70+ years old proteinuria
GFR 5-7 mL/min
Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80

86. 112 patients No diabetes, active
cancer, nephrotic range
70+ years old proteinuria
GFR 5-7 mL/min
Very low protein diet dialysis
Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80

87. VERY LOW PROTEIN
0.3 g protein per kilogram (RDA is 0.8)
Supplemented with keto-analogs of amino acids
and 4 essential amino acids
Initiate dialysis if they develop:
symptomatic uremia
volume overload
uncontrollable hypertension
hyperkalemia
Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80

88. 40 of 56 patients (71%) of patients randomized to diet
initiated dialysis per protocol, median of 9.8 months
after randomization.
Mortality was equal in the two groups:
31 deaths in the dialysis group
28 in the diet group
Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80

89. Brunori et al. Am J Kidney Dis 2007 vol. 49 p. 569-80

90. odds ratio for survival, 2.21; 95% CI, 1.02 to
4.83; P=0.04).
Brunori et al. Am J Kidney Dis 2007 vol. 49 p. 569-80

91. Dialysis Diet (ITT) Diet (PP) Diet (on dialysis)
1.2 12
0.9 9
0.6 6
0.3 3
0 0
admission/year Hosp days/year
Brunori et al. Am J Kidney Dis (2007) vol. 49 (5) pp. 569-80

92. ESRD
Healthy
but old

93. Multi-specialty clinic
Twelve nephrologists engaged in outpatient CKD
care in a structured CKD clinic at 5 outpatient
clinics

94. 200 consecutive patients
GFR less than 45 mL/min twice, 3 months apart
Age >65
GFR falls below 45 mL/min after Jan 1, 2004
Retrospective chart review
Endpoints: death, ESRD, hospitalizations

95. 199 patients
117 women, 82 men
150 Caucasians, 48 African Americans, 1 Asian
Average age 75.5 (65-96)
Follow-up:
Average 3.2 years
639 patient years

96. GFR Co-morbidities
Average 30 mL/min DM 88 patients
Minimum 10 mL/min HTN 194 patients
Maximum 45 mL/min CAD 90 patients
CVA 21 patients
Ca 62 patients

97. OUTCOMES
Died prior to dialysis: 18
End-stage renal disease: 20
10%
Transplant 1 9%
Hemodialysis 18
Peritoneal dialysis 1
81%
ESRD Death No endpoint

98. Delta GFR vs follow up
40
30
Average progression 1.1 mL/min per year
20
loss of GFR (ml/min/yr)
10
0
0 1 2 3 4 5 6 7 8 9 10
-10
-20
-30
-40

99. initial delta Blood
Age f/u Hgb
eGFR eGFR pressure
ESRD 74.1 1,028 21 4.5 147/73 11.3
Death 76.2 775 28 6.1 136/74 11.6
Alive 75.6 1,235 30 0.1 140/72 12.5

100. 25 OH D
Ca Phos iPTH 25 OH D
Checked
ESRD 8.9 4.0 159.9 10% 10.5
Death 9.1 3.7 146.5 22% 23.5
Alive 9.3 3.5 95.6 29% 23.2
Only 2, 4, and 47 patients had 25 OH vitamin D checked

101. 60
ESRD Death Alive
45
30
15
DM
CAD 0
CVA
PVD
Ca

102. DIALYSIS ACCESS
All of the ESRD patients received access except the
one preemptively transplanted
Quinton
Of the 18 who started hemodialysis: 6%
Fistula
7 fistulas Pcath 39%
33%
4 grafts
Graft
6 permacaths
22%
1 Temporary quinton

103. DIALYSIS ACCESS
None of the 18 patients who died received an access
Of the 161 who are alive and not ESRD, only 3
received an access
All received AVF
March of 2007, most recent visit March 2009
December 2006, most recent visit March 2009
May 2007, most recent visit March 2008

104. SUMMARY
Our data is fresh and has yet to be vetted by the
skeptical eye of the biostatistician
ESRD appears more common with
lower eGFR
higher PTH
faster progression

105. GERIATRIC CKD
Half of patients over 69 have CKD
Two-thirds of them have CKD stage 3 or higher
Patients are more likely to die than develop to ESRD
Despite this it is the fastest growing age demographic
with ESRD