Chronic disease management in older people with advanced CKD Shelagh O’Riordan Consultant Geriatrician and BGS representative on recent NICE CKD guidelines

What I will be talking about:  The approach to CKD as a geriatrician  Diagnosis and classification of CKD  Anaemia  Bones  Acidosis  Heart failure  Summary

Frailty and CKD  Frailty very common in CKD (more so than those without)  Functional impairment  Cognitive impairment- even younger patients with moderate CKD have measurable cognitive impairment  Older people more influenced by potential for side effects of treatment than potential risk reduction  Are renal physicians actually geriatricians?  Are geriatricians actually partly renal physicians?

Mrs A  76 y o woman  CKD stage 4, severe OA, hypertension, diabetes  GFR 25-30, 2+ protein on urine dip, BP 145/90  Difficulty getting out of chair, especially at the end of the day  Family live nearby but has difficulty getting out of the house to be involved in their lives  Codeine based analgesia cause severe constipation  Asks if she can take NSAIDS for her knee pain

Do we have a different perspective? Disease orientated approach  History related to kidney function- oedema, BP etc. Assess progression and CVD risk  Increase ACEI for BP control as high risk CVD and progression  Assess knee pain likely not to be related to kidneys  Use of NSAIDs likely to worsen function  Goal of treatment- preserve renal function, reduce CVD risk Person orientated approach  Comprehensive geriatric assessment (CGA)  Acknowledge conflicting priorities with NSAID use  Consider other options eg therapy, assistive devices, other analgesia  If really can’t cope without NSAIDS, change ACEI to different antihypertensive agents  Goal of treatment- what matters most to patient, preserving independence, planning for the future

Diagnosis of kidney disease

The debate rages on…… Age calibrated classification of CKD  Doesn’t take into account normal aging  Incorrect labelling of older people with CKD- overdiagnosis  40-50% of the population will develop CKD in their lifetime!  Suggests a new classification for older people starting at eGFR of 45 Continue with current classification  CKD is commoner in older people- so is hypertentsion, diabetes, hyperlipaemia- all increase risk of CVD  Not a consequence of normal aging- wide variation in eGFR and protein  Low eGFR and high protein excretion related to higher mortality  Age calibration will be too complicated

Did NICE CKD 2014 tackle this issue?  Use creatinine based equation CKD-EPI  If eGFRcreatinine and no other signs of CKD, do an eGFRcystatinC  Do not diagnose CKD in people with:  an eGFRcreatinine of 45–59 ml/min/1.73 m2 and  an eGFRcystatinC of more than 60 ml/min/1.73 m2 and  no other marker of kidney disease  Significant proportion of older people with very low risk of problems from CKD removed from the “CKD List”

Updated categories of CKD

Anaemia in CKD  Managing renal anaemia improves QOL  May have a role in treatment even for very frail patients  Investigate if Hb<110g/L or symptomatic  Diagnose iron deficiency and treat first but if target Hb not reached after 6M consider referral  IV iron to keep %hypochromic red cells <6%  Epo to keep Hb g/L  Trial of treatment- stop if not improving symptoms.

Renal bone disease and osteoporosis  Significant increase in hip fracture if eGFR<60  In men 50-74y 3x increase CKD in those with hip fracture than those without  High risk hip fracture if on dialysis  Difficult to treat

Treatment options for osteoporosis in CKD  Diagnose vitamin D deficiency in same way you normally would  Use 1-alpha hydroxylated vitamin D if eGFR <30mmol/l and monitor calcium  Use oral bisphosphonates if eGFR >30mmol/l  Only use IV zoledronic acid if eGFR >35ml/min/m2 and clinically indicated  Can use denosumab if eGFR <30 but not if on dialysis or eGFR<15- high risk of hypocalcaemia  Don’t forget your best treatment might be falls prevention!!

Should we treat metabolic acidosis in older people? Advantages  Metabolic acidosis common in advanced CKD  Leads to muscle weakness, fractures and CVD  Evidence of reduction in disease progression  Evidence of improved nutrition Disadvantages  Bulky, difficult to take tablets- 3/d  Increase sodium load- fluid retention, increase BP  GI side effects  No evidence improves quality of life

Fluid overload and CKD  Always difficult  Symptom control versus kidney function?  Poor long term prognosis  What about other drugs towards end of life?

Mr D - 82 year old gentleman: short of breath for 2 weeks, gradually increasing, high INR - Background: ICM with biventricular PPM, IHD – PCI to LAD, AF, stage 3B CKD (baseline eGFR 32), gout, BPH, diabetes - Medications: Aspirin 75mg od, Clopidogrel 75mg od, Warfarin, Allopurinol 100mg od, Lisinopril 5mg od, Digoxin 250mcg od, Finasteride 5mg od, Atorvastatin 40mg od, Furosemide 40mg bd, Gliclazide 40mg bd, codydramol 2 QDS - Recent acute gout: treated with 5/7 Naproxen 500mg bd - On admission: heart rate 118/min, BP 93/63, fluid overloaded, drowsy - Bloods: Hb 112, Na 132, K 5.7, creatinine 287 (eGFR 19), ALT 488, ALP 316, CRP 20, INR 13.5, Glucose 4.5

Management plan - Stop ACEI- more effect on kidney function than diuretics - Stop warfarin, aspirin and clopidogrel - Check digoxin level- stop digoxin - Stop codeine based analgesia - Stop gliclazide - High dose IV frusemide- started at 80mg IV am and lunchtime - Daily weights- much easier than input-output charts! Fluid restrict - SBP consistently mmHg - Continued deterioration in renal function: Cr 287 – 352 in 2 days- diuretic dose increased to 120mg am, 80mg lunchtime - Slowly started to lose weight - Renal function started to improve and back to near normal by day 7 - Symptomatically much improved

Points to remember  High dose diuretic better for symptom control than ACEI  Renal function and blood pressure may improve if off loaded  Diabetes drugs especially sulphonylureas need reviewing- prolonged hypoglycaemia  How long to fluid restrict?  Consider using palliative care medications and referral early rather than late  Which opiate is best in CKD?

What message to take home in later stages CKD- the geriatricians opinion!  Don’t make renal function and disease progression your main goal  All the skills of the geriatrician are required to get it right  New ways to diagnose and classify CKD- but these won’t affect acute care  Advised you on current management of some of the acute presentations- fractures, anaemia, CCF  Await answers to trials on treatment of acidosis  Work together with the primary care team, renal team and palliative team to provide best care for your patient