Elderly patients with chronic kidney disease: outcomes after 5 years of follow-up.

INTRODUCTION: In recent years, chronic kidney disease (CKD) has come to be considered an epidemic problem, and there is considerable interest in early diagnosis in order to slow its progression to end-stage renal disease (ESRD) and prepare patients for dialysis and transplantation programmes. Many elderly patients are labelled as having CKD based solely on having a glomerular filtration rate (GFR) of <60 ml/min. OBJECTIVE: Monitor renal function (RF) and outcomes associated with CKD (morbidity, mortality and progress to ESRD) in an elderly cohort. PATIENTS AND METHOD: A total of 80 clinically stable patients, with a median age of 83 years (range 69-97; 69% female, 35% diabetic, 83% hypertensive) were recruited at random in our Geriatric Medicine and Nephrology Departments between January and April 2006, and monitored for 5 years. During the recruitment stage we established two groups based on baseline serum creatinine (SCr) concentration: Group 1, 38 patients with SCr <1.1mg/dl (range 0.7-1.1) and Group 2, 42 patients with SCr >1.1mg/dl (range 1.2-3). We determined baseline blood levels of creatinine and urea, calculated eGFR using an abbreviated Modification of Diet in Renal Disease (MDRD) formula, and repeated these measurements after 5 years. We recorded baseline comorbidity according to the Charlson comorbidity index (CCI); hospital admissions; new cardiovascular events; treatments; progression to ESRD requiring dialysis; and mortality. RESULTS: In the 39 patients surviving after 5 years there were no significant differences between Groups 1 and 2 in total number of hospital admissions, episodes of heart failure and new ischaemic heart disease. Overall, the most commonly used drugs were diuretics (76.9%), while beta-blockers were used the least (10.3%). There were 41 deaths (51.3%): of these patients, 15 died due to overall decline, 8 due to infections, 4 due to stroke, 4 due to neoplasia, 3 due to cardiovascular problems, 2 due to complications from fractures and 5 due to unknown causes. Mortality was higher in Group 2 (66.7% vs 34.2%, P=.004) and patient age was also higher in that group (84.73 ± 5.69 vs 80.12 ± 6.5, P=.001). No significant differences in mortality were attributable to sex, diabetes, hypertension or CCI. Only 2 patients in Group 2 progressed to ESRD, they received conservative treatment due to comorbidity (no patients in the study have started dialysis). The evolution of RF (baseline/5 years) in all patients surviving at 5 years was as follows: SCr (mg/dl): 1.15 ± 0.41/1.21 ± 0.49 (not significant [NS]), urea (mg/dl) 52.21 ± 13.0/61.21 ± 27.0 (P=.047), MDRD (ml/min/1.73m2) 57.47 ± 15/54.86 ± 17 (NS). There were no differences in progression between the 2 groups. In the logistic regression analysis for overall mortality (independent variables: age, sex, CCI, cardiovascular history, SCr and group), only age (relative risk [RR]: 1.12; 1.03-1.23, P=.009) and group (RR: 3.06; 1.10-8.40, P=.031) were independently associated with mortality. CONCLUSION: Screening for CKD using GFR only may lack clinical relevance in this population since RF slowly deteriorates in elderly patients without proteinuria. Mortality due to all causes was higher in elderly patients with a poorer baseline RF, and mortality rates were higher than rates of CKD progression to ESRD.

Renal supportive care and palliative care: revision and proposal in kidney replacement therapy.

Patients with chronic kidney disease may receive sustained renal supportive care and renal palliative care (RPC) starting with the diagnosis of the disease, throughout the various stages of renal replacement therapy (RRT), the cessation of the RRT, and in the decision of whether to provide conservative treatment or non-initiation of RRT. This article reviews the literature on the development of renal palliative care and proposed RPC models. We describe the progression of disease in organ failure, which is very different from other areas of palliative care (PC). We describe important components of resident nephrology training in PC. We discuss the management of pain and symptom control, as well as communication skills and other psychological and ethical aspects in the renal patient. We conclude that in chronic renal patients, a palliative care approach can provide a positive impact on the quality of life of patients and their families, as well as optimizing the complex treatment of the renal patient.

Serum uric acid as a marker of all-cause mortality in an elderly patient cohort.

INTRODUCTION: There is growing evidence of the role of serum uric acid (SUA) as a risk factor for cardiovascular and renal disease. We analysed the association between baseline SUA and overall mortality in a cohort of elderly patients followed prospectively for 5 years. PATIENTS AND METHODS: Eighty clinically stable patients, median age 83 years (range 69-97), 31.3% men, 35% diabetics, 83% hypertensives were randomly recruited at Geriatrics and Nephrology visits between January and April 2006 and followed for 5 years. We measured baseline SUA and serum creatinine and estimated glomerular filtration rate (GFR) with MDRD abbreviated. In Nephrology Department patients, we measured proteinuria in 24-hour urine and in Geriatrics department patients we measured proteinuria (mg/dl)/creatinine (mg/dl) in urine (first morning urine). Predictive variables were: baseline SUA and plasma creatinine; estimated GFR (abbreviated MDRD formula); and we recorded age, gender, baseline comorbidity (Charlson index), individualised cardiovascular treatment and mortality. STATISTICAL ANALYSIS: SPSS15.0. RESULTS: baseline SUA was normally distributed and its median was 5.85 mg/dl. We found no significant differences in levels of SUA by gender, history of diabetes mellitus, hypertension, diuretic drug use, heart disease, peripheral arterial disease or stroke. Patients with a history of heart failure had significantly higher SUA (7.00 ± 1.74 vs 5.90 ± 1.71, P=.031). Some 41 deaths occurred during follow-up (15 men and 26 women): 15 due to general deterioration, 8 due to infections, 4 due to stroke, 4 due to tumours, 3 due to cardiovascular disease, 2 due to complications of fractures and 5 due to unknown causes. Patients with SUA higher than the median had significantly lower GFR and higher mortality at 5 years. In the Cox analysis for overall mortality [independent variables: age, gender, Charlson Index, history of heart failure, SUA, creatinine, proteinuria and GFR (MDRD)] only SUA levels (HR: 1.35; 1.17-1.56 P=.000) were independently associated with mortality. CONCLUSIONS: In our study, levels of SUA are an independent risk factor for mortality in elderly patients.

[Renal biopsy in patients aged 65 years or older: are there differences in the indication and histopathology compared to other patients?]. / La biopsia renal en pacientes de 65 o más años: ¿existen diferencias en la indicación y en la histopatología respecto al resto de pacientes?

BACKGROUND: Renal biopsy (RB) represents the gold standard for diagnosis of kidney diseases. In this paper we analyse whether the indication of RB and histopathology in patients 65 years or older is different from the other patients. MATERIAL AND METHODS: Retrospective study of 93 native renal biopsies performed in the General Hospital of Segovia in the period 2004-2008. The RB was performed percutaneously under ultrasound guidance in real time, using a 16G automatic needle. RESULTS: Mean age of biopsied patients was 56.89 ± 19 (range 14-89) , and 57% were males. A total of 39RB were performed on people aged 65 years or older. Overall, nephrotic syndrome (NS) is the most common indication of RB, and IgA glomerulonephritis the most common histology. In people ≥ 65 years, acute renal failure (ARF) is the most common indication for RB, and rapidly progressing (crescentic) glomerulonephritis/vasculitis the most detected the diagnosis. When taking age into account, no significant differences in the number of glomeruli obtained by RB or in the number of RB performed on the same patient. CONCLUSIONS: In people 65 years or older, ARF is the main indication of RB and crescentic glomerulonephritis/vasculitis the most frequent diagnosis.

Nephrotic syndrome resulting from focal segmental glomerulosclerosis in a peripheral blood stem cell transplant patient.

We describe the case of a male patient who was diagnosed with acute monoblastic leukemia and received a peripheral stem cell transplantation (PSCT) with peripheral blood hematopoietic progenitors. Because he was in clinical remission with no evidence of chronic graft-versus-host disease (GVHD), immunosuppression was withdrawn, and he developed nephrotic syndrome (NS) months later. A kidney biopsy showed focal segmental glomerulosclerosis (FSGS) as part of the GVHD. Soon after the reintroduction of previous immunosuppressive therapy, we observed a complete remission of the NS.

Obstructive ARF caused by an inflammatory abdominal aortic aneurysm.

Inflammatory abdominal aortic aneurysms are rare entities characterized by dense fibrosis typically enveloping the aortic wall and adjacent structures with distinctive clinical features that differentiate them from typical atherosclerotic aneurysms. The inflammatory process can involve the renal excretory pathways, causing ureteral obstruction in 20% of cases. The authors report 2 cases of complete obstructive anuria secondary to inflammatory aneurysms and discuss the most appropriate management for these situations of hydronephrosis. Surgical repair of the aneurysm usually leads to regression of the inflammatory reaction.