Background-Little is known about the effects of hypokalemia on outcomes in patients with chronic heart failure (HF) and chronic kidney disease (CKD).

SummaryBackground and objectives Apparent treatment-resistant hypertension is defined as systolic/diastolic BP$140/ 90 mmHg with concurrent use of three or more antihypertensive medication classes or use of four or more antihypertensive medication classes regardless of BP level.Design, setting, participants, & measurements The prevalence of apparent treatment-resistant hypertension among Reasons for Geographic and Racial Differences in Stroke study participants treated for hypertension (n=10,700) was determined by level of estimated GFR and albumin-to-creatinine ratio, and correlates of apparent treatment-resistant hypertension among those participants with CKD were evaluated. CKD was defined as an albumin-to-creatinine ratio$30 mg/g or estimated GFR,60 ml/min per 1.73 m 2 .Results The prevalence of apparent treatment-resistant hypertension was 15.8%, 24.9%, and 33.4% for those participants with estimated GFR$60, 45-59, and ,45 ml/min per 1.73 m 2 , respectively, and 12.1%, 20.8%, 27.7%, and 48.3% for albumin-to-creatinine ratio,10, 10-29, 30-299, and $300 mg/g, respectively. The multivariableadjusted prevalence ratios (95% confidence intervals) for apparent treatment-resistant hypertension were 1.25 (1.11 to 1.41) and 1.20 (1.04 to 1.37) for estimated GFR levels of 45-59 and ,45 ml/min per 1.73 m 2 , respectively, versus $60 ml/min per 1.73 m 2 and 1.54 (1.39 to 1.71), 1.76 (1.57 to 1.97), and 2.44 (2.12 to 2.81) for albumin-tocreatinine ratio levels of 10-29, 30-299, and $300 mg/g, respectively, versus albumin-to-creatinine ratio,10 mg/g. After multivariable adjustment, men, black race, larger waist circumference, diabetes, history of myocardial infarction or stroke, statin use, and lower estimated GFR and higher albumin-to-creatinine ratio levels were associated with apparent treatment-resistant hypertension among individuals with CKD.Conclusions This study highlights the high prevalence of apparent treatment-resistant hypertension among individuals with CKD.

Antihypertensive medication and low systolic and diastolic blood pressure (SBP and DBP) have been associated with an increased falls risk in some studies. Many older adults have indicators of frailty, which may increase their risk for falls. We contrasted the association of SBP, DBP, number of antihypertensive medication classes taken, and indicators of frailty with risk for serious fall injuries among 5,236 REasons for Geographic and Racial Difference in Stroke study participants ≥65 years taking antihypertensive medication at baseline with Medicare fee-for-service coverage. SBP and DBP were measured and antihypertensive medication classes being taken assessed through a pill bottle review during a study visit. Indicators of frailty included low body mass index, cognitive impairment, depressive symptoms, exhaustion, impaired mobility and history of falls. Serious fall injuries were defined as fall-related fractures, brain injuries or joint dislocations using Medicare claims through December 31, 2014. Over a median of 6.4 years, 802 (15.3%) participants had a serious fall injury. The multivariable-adjusted hazard ratio for a serious fall injury among participants with 1, 2 or ≥3 indicators of frailty versus no frailty indicators were 1.18 (95% confidence interval [CI], 0.99–1.40), 1.49 (95%CI, 1.19–1.87) and 2.04 (95%CI, 1.56–2.67), respectively. SBP, DBP, and number of antihypertensive medication classes being taken at baseline were not associated with risk for serious fall injuries after multivariable adjustment. In conclusion, indicators of frailty, but not BP or number of antihypertensive medication classes, were associated with increased risk for serious fall injuries among older adults taking antihypertensive medication.

Among older veterans with moderate-to-severe CKD, multimorbidity presents a major challenge for CKD self-management. Because virtually all older adults with CKD have multimorbidity, an integrated treatment approach that supports self-management across commonly occurring conditions may be necessary to meet the needs of these patients.

The authors examined trends in systolic blood pressure (SBP) and diastolic blood pressure (DBP) and the prevalence, awareness, treatment, and control of hypertension in 1988–1994 (n=1164), 1999–2004 (n=1,026), and 2005–2010 (n=1048) among US adults 80 years and older in serial National Health and Nutrition Examination Surveys. Hypertension was defined as SBP ≥140 mm Hg, DBP ≥90 mm Hg, or use of antihypertensive medication. Awareness and treatment were defined by self‐report and control as SBP/DBP<140/90 mm Hg. Mean SBP decreased from 147.3 mm Hg to 140.1 mm Hg and mean DBP from 70.2 mm Hg to 59.4 mm Hg between 1988–1994 and 2005–2010. The prevalence, awareness, and treatment of hypertension each increased over time. Controlled hypertension increased from 30.4% in 1988–1994 to 53.1% in 2005–2010. The proportion of patients taking 3 classes of antihypertensive medication increased from 7.0% to 30.9% between 1988–1994 and 2005–2010. Increases in awareness, treatment, and control of hypertension and antihypertensive polypharmacy have been observed among very old US adults.

SummaryBackground and objectives It has been suggested that moderate reductions in estimated GFR (eGFR) among older adults may not reflect chronic kidney disease (CKD).Design, setting, participants, & measurements We examined age-specific (Ͻ60, 60 to 69, 70 to 79, and Ն80 years) associations between eGFR level and six concurrent CKD complications among 30,528 participants from the National Health and Nutrition Examination Survey (NHANES) 1988(NHANES) to 1994(NHANES) and 1999(NHANES) to 2006 (n ϭ 8242 from NHANES 2003 to 2006 for hyperparathyroidism). Complications included anemia (hemoglobin Ͻ12 g/dl women, Ͻ13.5 g/dl men), acidosis (bicarbonate Ͻ22 mEq/L), hyperphosphatemia (phosphorus Ն4.5 mg/dl), hypoalbuminemia (albumin Ͻ3.5 mg/dl), hyperparathyroidism (intact parathyroid hormone Ն70 pg/ml), and hypertension (systolic/diastolic BP Ն140/90 mmHg or antihypertensive use).Results Among participants Ն80 years old, compared with those with estimated GFR (eGFR) Ն60 ml/min per 1.73 m 2 , the multivariable adjusted prevalence ratios (95% confidence interval) associated with eGFR levels of 45 to 59 and Ͻ45 ml/min per 1.73 m 2 were 1.39 (1.11 to1.73) and 2.06 (1.59 to 2.67) for anemia, 1.33 (0.89 to 1.98) and 2.47 (1.52 to 4.00) for acidosis, 1.11 (0.70 to 1.76) and 2.16 (1.36 to 3.42) for hyperphosphatemia, 2.04 (1.39 to 3.00) and 2.83 (1.76 to 4.53) for hyperparathyroidism and 1.09 (1.03 to 1.14), and 1.12 (1.05 to 1.19) for hypertension, respectively. Higher prevalence ratios for these complications at lower eGFR levels were also present at younger ages. Reduced eGFR was associated with hypoalbuminemia only for adults Ͻ70. ConclusionsReduced eGFR was associated with a higher prevalence of several concurrent CKD complications, regardless of age.

The last decade has seen the evolution and ongoing refinement of a disease-oriented approach to chronic kidney disease (CKD). Disease-oriented models of care assume a direct causal association between observed signs and symptoms and underlying disease pathophysiology. Treatment plans target underlying disease mechanisms with the goal of improving disease-related outcomes. Because average levels of glomerular filtrate rate (GFR) tend to decrease with age, CKD becomes increasingly prevalent with advancing age, and those who meet criteria for CKD are disproportionately elderly. However, several features of geriatric populations may limit the utility of disease-oriented models of care. In older adults, complex comorbidity and geriatric syndromes are common, signs and symptoms often do not reflect a single underlying pathophysiologic process, there can be substantial heterogeneity in life expectancy, functional status and health priorities, and information on the safety and efficacy of interventions is often lacking. For all these reasons, geriatricians have tended to favor an individualized patient-centered model of care over more traditional disease-based approaches. An individualized approach prioritizes patient preferences and embraces the notion that observed signs and symptoms often do not reflect a single unifying disease process, and instead reflect the complex interplay between many different factors. This approach emphasizes modifiable outcomes that matter to the patient. Prognostic information related to these and other outcomes is generally used to shape rather than dictate treatment decisions. We herein argue that an individualized patient-centered approach to care may have more to offer than a traditional disease-based approach to CKD in many older adults.

In community-dwelling older adults, CKD is associated with IADL and BADL decline.