Chapter 83: Kidney Diseases

Learning Objectives

• Recognize that chronic kidney disease (CKD) is most often caused by common systemic diseases, including diabetes and hypertension.

• Understand that diabetic nephropathy is a chronic progressive kidney disease that requires treatment with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blockers (ARBs) if tolerated, optimization of blood pressure and blood glucose levels, and management of comorbidities. SGLT2 inhibitors and GLP-1 receptor agonists show benefits in treatment of diabetes and substantial reduction of risk of kidney disease progression.

• Assess acute kidney injury (AKI) for pre-, post-, and intrarenal causes among the older adult. Even episodes of mild AKI can increase the risk for future CKD and the etiology of AKI is often related to the sex, age, and location of the patient.

• Understand the prognosis of older adults with kidney failure.

• Characterize the approaches to managing end-stage kidney disease (ESKD) 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 and concurrent cognitive impairment and frailty.

• Discuss the role of clinicians and care teams in advance care planning for patients with ESKD.

Key Clinical Points

1. In patients with CKD, management of elevated blood pressure and avoidance of nephrotoxins can delay progression to ESKD.

2. Complications of CKD include iron-deficient anemia and secondary hyperparathyroidism.

3. Proteinuria in the absence of hematuria is a sign of kidney damage, is a risk factor for prog­ression of CKD to ESKD, and requires evaluation.

4. In patients with renovascular disease, intervention is usually only indicated if conservative management fails.

5. Clinical guidelines suggest that patients with progressive 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.

6. 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.

7. There are no age restrictions on access to kidney transplantation in the United States. Older kidney transplant patients tend to have less kidney allograft rejection and a higher complication rate from infections.

8. 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.