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Essentials of Diagnosis

  • Evaluation of chronic kidney disease (CKD) includes a thorough medical history, physical exam, and specific laboratory measures.

  • Symptoms related to CKD may not occur until disease is advanced and include sleep disturbance, decreased attentiveness, nausea, vomiting, weight change, dyspnea, lower extremity edema, fatigue, muscle cramps, peripheral neuropathy and pruritus.

  • Reduced estimated glomerular filtration rate (eGFR) (<60 mL/min/1.73 m2) should be interpreted in the context of the medical history and other lab abnormalities (eg, history of diabetic retinopathy, rate of eGFR decline, presence of elevated albumin-to-creatinine ratio) before a diagnosis of CKD is made.

General Principles in Older Adults

Chronic kidney disease (CKD) is defined as the presence of reduced glomerular filtration rate (GFR) or evidence of kidney damage for at least 3 months, which becomes increasingly common at older ages. In older populations, GFR should be estimated using a prediction equation. CKD stage should be assigned based on the level of kidney function. The vast majority of older adults with CKD will die without progressing to end-stage renal disease (ESRD); however, even mild-to-moderate CKD is associated with functional decline, cognitive impairment, frailty, and complex comorbidity.

The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) disease-specific guidelines have been established to direct the evaluation and management of patients with CKD; however, because of the substantial heterogeneity in life expectancy, functional status and health priorities among older adults with CKD, an individualized, patient-centered approach might be helpful. Special considerations must be made when treating CKD-related comorbidities and complications. Among older adults with advanced CKD, a shared decision-making approach should be used to facilitate decisions about dialysis. Geriatric assessment may be helpful to identify older adults who are vulnerable to functional decline and poor outcomes after initiation of dialysis. Palliative and supportive care should be offered to those who experience a high symptom burden regardless of disease stage and dialysis decision.

Pathogenesis

The NKF/KDOQI Clinical Practice Guidelines provide standardized terminology for the evaluation and stratification of CKD. Based on these guidelines, CKD is defined as the presence of reduced GFR or evidence of kidney damage for at least 3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, most frequently identified by albuminuria. This CKD definition is based on GFR and kidney damage, regardless of the underlying kidney disease etiology.

Among older adults, serum creatinine is a poor marker of kidney function. However, because measuring GFR is not clinically feasible, GFR should be estimated using prediction equations based on the serum creatinine and other factors affecting creatinine production including age, race and gender. Multiple estimating formulas are available (see www.kidney.org/professionals/kdoqi/gfr_calculator.cfm) including the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Although there is no consensus on which formula should be used for older adults, the CKD-EPI equation may be superior, ...

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