Namirah Jamshed M.B;B.S Associate Professor of Clinical Medicine Georgetown University School of Medicine MedStar Washington Hospital Center ©AAHCM

 76 year old AA lady  PMH ◦ CKD ◦ CHF ◦ CAD ◦ CVA ◦ HTN ◦ Peripheral neuropathy ◦ DM ◦ Anemia  SH ◦ Home/Son ◦ PCA services 14hrs/day  Medications ◦ Lantus ◦ Metoprolol ◦ Hydralazine ◦ Furosemide ©AAHCM

 ~ 44% in ≥ 65 years  60% -69% ≥ 80 years age  Stage III 70-77%  ↑CHF, CAD, CVA, PVD, HTN  Lesley A. Stevens et al. Am J Kidney Dis 55(S2):S23-S33. © 2010 by the National Kidney Foundation, Inc ©AAHCM

 Age  Comorbidity  Functional status  Albumin  Cognitive impairment ©AAHCM

 Glycemic Control  ACE inhibitor or ARB therapy  Blood Pressure Control  Dietary restriction of protein ©AAHCM

 Mental Health Disturbance ◦ State of Mind ◦ Cognitive Abilities  Falls  Multimorbidity management ◦ Willingness or capacity to comply  Medication maangement ©AAHCM

Paternelism Beneficence RRT: Default pathway?

 What one can to ensure that their wishes and preferences are consistent with the health care treatment they might receive if they were unable to speak for themselves or make their own decisions.  ©AAHCM

 Initiate prior to the need for dialysis  Include family in discussion  Family support  Family influence  Family involvement  Provide detailed information as part of pre- dialysis education  Logistics of scheduling and transport ©AAHCM

Typical Illness Trajectories For Chronic Murray S A et al. BMJ 2005;330: ©AAHCM

Moss, Clin J Am Soc Nephrol 3: , 2008 ©AAHCM

 8% vs 12% survival to hospital discharge  3% vs 9% alive in 6 months  Neurolgical compromise or mechanical ventilation  Moss AH, Holley JL, Upton MB. Outcomes of cardiopulmonary resuctitation in dialysis patients. J Am Soc Nephrol. 1992;3(6);  Expectations ◦ 87% wanted CPR ◦ Blacks > White (OR 6.56, CI 95%)  Moss AH, Hozayen O, King K et al. Attitudes of paitens toward cardiopulmonary resucitation in the dialysis unit. Am J Kidney Dis. 2001;38(4): ©AAHCM

2013 Low albumin Anemia azotemia 2014 ? Twitching; Myoclonus; seizure ©AAHCM

CKD Status Stage Knowledge Prognosis Co-morbid Conditions CVD HTN DM Pyscho-social issues Cognition Support Adherence Burdens of Dialysis Physical Financial Logistics Caregiver Advance Care Planning