Managing Chronic Kidney Disease in Older People—Reply

Abstract

In Reply Because our study was a phase 2B trial with the purpose of finding the optimal dosage with which to conduct a phase 3 outcome trial, strong conclusions should not be drawn from the results. Although Dr Feng and colleagues are correct that change in UACR at day 90 was the primary end point, we understand this is not consistent with any valid renal outcome and is a marker of inflammation and cardiovascular risk rather than renal injury. 1 We are fully aware of the variable relationship of high albuminuria and both kidney disease and cardiovascular outcomes from powered trials.We did not provide data on blood pressure variability because this was not a prespecified primary or secondary end point, although we are aware of the increased cardiovascular risk associated with increased blood pressure variability. We did perform ambulatory blood pressure monitoring in a subgroup of patients, and these data will be analyzed in the future.Hypotension was reported as an adverse event in less than 1% of patients; all events were of mild intensity, and none resulted in modification of drug therapy or any action with study drug.We appreciate the comment about dosing of ACE inhibitors and angiotensin receptor blockers contributing to greater effects on UACR; however, the study did not allow for titration of ACE inhibitors or angiotensin receptor blockers unless blood pressure was significantly elevated. In our trial, there was no significant uptitration of ACE inhibitors or angiotensin receptor blockers. Thus, the data are not confounded by increased dosing of other renin-angiotensin system-blocking therapies.We agree that outcome studies are needed and we have started studies involving 3 outcomes of diabetic kidney disease: kidney failure, cardiovascular outcomes, and heart failure. The first 2 trials are now recruiting patients and the heart failure trial will start within the next few months.

Prevalence and factors associated to chronic kidney disease in older adults

“…The high prevalence of older adults with CKD, especially those with 70 years or more, according to the criteria of the Kidney Disease: Improving Global Outcomes (KDIGO) 2012, has been questioned by researches who defend a new definition of CKD for older adults, not classifying individuals in stage 3a as sick, but only those with GFR < 45 ml/min/1,73 m 2 and the presence of albuminuria 20 . This proposal would reduce the prevalence of renal injury in this study.…”

GFR Evaluation in Living Kidney Donor Candidates

“…There is debate about whether the lower GFR in older people represents normal aging or disease. [20][21][22][23] There is some evidence that the normal level of GFR varies among ethnic groups. 24 Studies of kidney donor candidates report lower mean GFR, but the interpretation is limited by selection criteria and differences in GFR measurement methods 25,26 In principle, GFR is the product of the number of nephrons (N) and the average single nephron GFR (SNGFR).…”

Age and the eGFR-dependent risk for adverse clinical outcomes

“…Some members of the kidney community have raised concerns that the current CKD definition based on a single eGFR threshold artificially inflates the size of the population with CKD by labeling many older adults who have an age-related decline in kidney function with a disease that they do not have [ 5 ]. Existing studies on how age may modify the association between eGFR and adverse outcomes have been interpreted to support opposite views of how eGFR should be used to define CKD [ 6 ], especially in the majority of adults who are 65 years old or older and have an eGFR between 45 and 59 mL/min/1.73 m 2 with normal or mild albuminuria [ 7 ]. In this article, we first review epidemiological measures of outcome occurrence and association.…”