The increasing number of older patients with renal disease

Sims, Rebecca; Cassidy, Michael J.; Masud, Tahir

doi:10.1136/bmj.327.7413.463

Cited by 33 publications

(20 citation statements)

References 9 publications

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“…Second, the average age of our cohort was 71 yr. Although this fully reflects the progressive aging of the population of individuals who have CKD and are referred to renal clinics (35), our findings may not apply to younger cohorts. Third, our cohort was relatively small, and the number of events recorded during the study was limited, yet our statistical approach modeling competing risks and considering multiple outcomes was powerful enough for establishing an independent association between ADMA and death and the renal outcome.…”

Section: Discussionmentioning

confidence: 72%

Asymmetrical Dimethylarginine Predicts Progression to Dialysis and Death in Patients with Chronic Kidney Disease

Ravani

Tripepi²,

Malberti³

et al. 2005

Journal of the American Society of Nephrology

351

250

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High plasma asymmetrical dimethylarginine (ADMA) signals endothelial dysfunction and atherosclerosis in the general population and predicts mortality in ESRD. The relationship among plasma levels of ADMA, renal function, and the risk for progression to ESRD (halving GFR or dialysis start) and death in an incident cohort of 131 patients with chronic kidney disease was investigated. Cox's competing risk regression was used to model double-failure times (progression to ESRD and death) as a function of ADMA. Covariates that were considered for adjustment included clinical characteristics, baseline GFR (Modification of Diet in Renal Disease equation 7 formula), proteinuria, traditional cardiovascular risk factors, serum C-reactive protein, homocysteine, and concomitant therapies. Mean age at enrollment was 71 ؎ 11 yr, and 24% of patients had diabetes. Baseline GFR ranged from 8 to 77 ml/min per 1.73 m 2 (average 31 ؎ 15 ml/min per 1.73 m 2 ). ADMA was inversely related to GFR, ranking as the third predicting factor (partial r ‫؍‬ ؊0.22, P ‫؍‬ 0.01), after hemoglobin and urinary protein, in a general linear model that included multiple correlates of GFR. After a mean follow-up of 27 mo (range 3.4 to 36), 29 patients progressed to ESRD and 31 died. ADMA (hazard ratio per 0.1 M/L 1.203; 95% confidence interval 1.071 to 1.350) predicted event occurrence independent of other potential confounders, including GFR, proteinuria, hemoglobin, and homocysteine. In patients with mild to advanced chronic kidney disease, plasma ADMA is inversely related to GFR and represents a strong and independent risk marker for progression to ESRD and mortality. These novel findings further expand the implications of previous observations in ESRD patients and generate hypotheses on the role of ADMA in progressive chronic nephropathies.

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Section: Discussionmentioning

confidence: 72%

Asymmetrical Dimethylarginine Predicts Progression to Dialysis and Death in Patients with Chronic Kidney Disease

Ravani

Tripepi²,

Malberti³

et al. 2005

Journal of the American Society of Nephrology

351

250

View full text Add to dashboard Cite

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“…In Europe (including the U.K., which through the 1970s and 80s applied the most stringent age-specific criteria for treatment), the numbers are comparable (Rothenberg, 1992;Stanton, 1999). Over half of European patients undergoing dialysis in 2003 were over age 65 (Sims, Cassidy, & Masud, 2003). There is wide variation across countries in the rates of ESRD patients initiating hemodialysis: 310 patients per million population in the U.S.; 77 per million in the UK; 148 per million in Germany; and 104 per million in Italy (Lambie, Rayner, Bragg-Gresham, Pisoni, Andreucci, Canaud, et al, 2006).…”

Section: The Emergence Of Geriatric Dialysismentioning

confidence: 95%

The value of “life at any cost”: Talk about stopping kidney dialysis

Russ

Shim

Kaufman

2007

Social Science & Medicine

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With the trend toward an older, sicker dialysis population in the USA, discussions of ethical issues surrounding dialysis have shifted from concerns about access to and availability of the therapy, to growing unease about non-initiation and treatment discontinuation. Recent studies report treatment withdrawal as the leading cause of death among elderly dialysis patients. Yet, the actual activities that move patients toward stopping treatment often remain obscure, even to clinicians and patients themselves. This paper explores that paradox, drawing on anthropological research among patients over age 70, their families, and clinicians in two California renal dialysis units. It concludes that many older patients sacrifice a sense of choice about dialysis in the present to maintain "choice" as both value and possibility for the future. Yet, patients desire more information and communication, provided earlier in their illness, about prognosis, how long they can expect to be on dialysis, and what the impact of the treatment will be on their daily lives. That, with time, there is a transition to be made from dialysis as "treatment" to end of life care could be better explained and managed to alleviate patients' confusion and unneeded isolation.

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“…In the context of that trial, at all stages of CKD and independently of proteinuria, the risk of ESRD was uniformly higher than that of death. MDRD study was on the basis of a relatively young population (average age 50 years) of nondiabetic patients with a low burden of cardiovascular comorbidities (8%), whereas our cohort, which reflects the population now commonly seen in nephrology clinics in Europe (38), had an average age of 67 years and included large fractions of diabetics (28%) and of patients with CV disease (32%). Therefore, the TABLE study, on the basis of patients reflecting today's CKD population on stable nephrology care, confirms that ESRD rather than death is the dominant clinical outcome in patients on long term follow-up in nephrology offices.…”

Section: Discussionmentioning

confidence: 99%

Prognosis of CKD Patients Receiving Outpatient Nephrology Care in Italy

Nicola

Chiodini

Zoccali³

et al. 2011

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Prognosis in nondialysis chronic kidney disease (CKD) patients under regular nephrology care is rarely investigated.Design, setting, participants, & measurements We prospectively followed from 2003 to death or June 2010 a cohort of 1248 patients with CKD stages 3 to 5 and previous nephrology care Ն1 year in 25 Italian outpatient nephrology clinics. Cumulative incidence of ESRD or death before ESRD were estimated using the competing-risk approach.Results Estimated rates (per 100 patient-years) of ESRD and death 8.3 (95% confidence interval [CI], 7.4 to 9.2) and 5.9 (95% CI 5.2 to 6.6), respectively. Risk of ESRD and death increased progressively from stages 3 to 5. ESRD was more frequent than death in stage 4 and 5 CKD, whereas the opposite was true in stage 3 CKD. Younger age, lower body mass index, proteinuria, and high phosphate predicted ESRD, whereas older age, diabetes, previous cardiovascular disease, ESRD, proteinuria, high uric acid, and anemia predicted death (P Ͻ 0.05 for all). Among modifiable risk factors, proteinuria accounted for the greatest contribution to the model fit for either outcome. ConclusionsIn patients receiving continuity of care in Italian nephrology clinics, ESRD was a more frequent outcome than death in stage 4 and 5 CKD, but the opposite was true in stage 3. Outcomes were predicted by modifiable risk factors specific to CKD. Proteinuria used in conjunction with estimated GFR refined risk stratification. These findings provide information, specific to CKD patients under regular outpatient nephrology care, for risk stratification that complement recent observations in the general population.

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The increasing number of older patients with renal disease

Cited by 33 publications

References 9 publications

Asymmetrical Dimethylarginine Predicts Progression to Dialysis and Death in Patients with Chronic Kidney Disease

Asymmetrical Dimethylarginine Predicts Progression to Dialysis and Death in Patients with Chronic Kidney Disease

The value of “life at any cost”: Talk about stopping kidney dialysis

Prognosis of CKD Patients Receiving Outpatient Nephrology Care in Italy

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