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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #26

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LEARNING OBJECTIVES

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Learning Objectives

  • Describe the indications for initiating dialysis among older adults with kidney failure.

  • Understand the prognosis of older adults with kidney failure.

  • Characterize the approaches to managing end-stage kidney disease among older adults.

  • Describe the influence of multiple chronic health conditions on quality of life and functioning among older adults with kidney failure.

  • Recognize the challenges in providing care to older patients with kidney failure due to increased cognitive impairment and frailty.

  • Discuss the role of clinicians in advanced care planning for patients with end-stage renal disease (ESRD).

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Key Clinical Points

  1. In addition to diabetes and hypertension, pauci-immune glomerulonephritis, renovascular disease, and acute kidney injury (AKI) contribute to the growing numbers of older patients with kidney failure.

  2. Clinical guidelines suggest that patients with progressive chronic kidney disease (CKD) should be managed in a multidisciplinary setting. Nephrologist referral should be considered under the following circumstances: AKI, urinary red cell casts, CKD and refractory hypertension, persistent abnormalities of potassium, recurrent or extensive nephrolithiasis, hereditary kidney disease, CKD stages 4 and 5, and patients with severely increased albuminuria.

  3. Older patients with kidney failure have a multitude of choices for kidney replacement therapy including hemodialysis, peritoneal dialysis, conservative management, palliative care, and kidney transplantation.

  4. There are no age restrictions on access to kidney transplantation in the United States. Among older patients with kidney failure, it is important to consider kidney transplantation as an option. Older kidney transplant patients tend to have less kidney allograft rejection and a higher complication rate from infections.

  5. Kidney failure is associated with a markedly high mortality rate among older patients initiating dialysis—average 1-year survival rate is 50% for octogenarians and nonagenarians who start dialysis.

  6. There are major gaps in advanced care planning for patients with chronic kidney failure. Geriatricians and nephrologists should work together to establish goals of care for these high-risk patients.

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DEFINITION

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End-stage renal disease (ESRD) or kidney failure, has been defined as having kidney function less than 15 mL/min/1.73 m2. Kidney failure may be caused by progression of a chronic nephropathy or by acute kidney injury (AKI). Kidney failure is associated with the inability to excrete waste products, control serum electrolytes, handle the daily dietary and metabolic acid load, and maintain fluid balance. In addition, kidney failure causes inadequate production of erythropoietin, deranged calcium and phosphorous metabolism, high blood pressure, and accelerated progression of cardiovascular disease. Uremia is the term used to describe the symptoms or symptom complex attributable to advanced kidney failure or ESRD. Most chronic nephropathies demonstrate inexorable progression to kidney failure. While it is widely held that there is a straight line relationship between the decrement in kidney function over time when the kidney function is plotted longitudinally, there is variability in rate and trajectory of progression among individuals with kidney disease. This variability may be particularly important ...

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