Youth, which is forgiven everything, forgives itself nothing: age, which forgives itself everything, is forgiven nothing.
George Bernard Shaw
The proportion of older people in the general population is steadily increasing worldwide,
with the most rapid growth in low- and middle-income countries.11. World Health Organization. Good health adds life to years: Global
brief for World Health Day 2012. Geneva; 2012. This demographic change is to be celebrated, because it is the
consequence of socioeconomic development and better life expectancy. However, population
aging also has important implications for society - in diverse areas including health
systems, labor markets, public policy, social programs, and family dynamics.22. Wiener JM, Tilly J. Population ageing in the United States of
America: implications for public programmes. Int J Epidemiol 2002;31:776-81. DOI:
http://dx.doi.org/10.1093/ije/31.4.776
http://dx.doi.org/10.1093/ije/31.4.776...
A successful response to the aging population will
require capitalizing on the opportunities that this transition offers, as well as
effectively addressing its challenges.
Chronic kidney disease (CKD) is an important public health problem that is characterized by
poor health outcomes and very high health care costs. CKD is a major risk multiplier in
patients with diabetes, hypertension, heart disease and stroke - all of which are key
causes of death and disability in older people.33. Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of
chronic kidney disease to the global burden of major noncommunicable diseases. Kidney
Int 2011;80:1258-70. PMID: 21993585 DOI:
http://dx.doi.org/10.1038/ki.2011.368
http://dx.doi.org/10.1038/ki.2011.368...
Since the prevalence of CKD is higher in older people, the health impact of population
aging will depend in part on how the kidney community responds.
March 13, 2014 will mark the celebration of the 9th World Kidney Day (WKD), an annual event jointly sponsored by the International Society of Nephrology and the International Federation of Kidney Foundations. Since its inception in 2006, WKD has become the most successful effort to raise awareness among policymakers and the general public about the importance of kidney disease. The topic for WKD 2014 is "CKD in older people". This article reviews the key links between kidney function, age, health and illness - and discusses the implications of the aging population for the care of people with CKD.
Epidemiology of aging
The key drivers of population aging are socioeconomic development and increasing prosperity - which result in lower perinatal, infant and childhood mortality; lower risk of death in early adulthood due to accidents and unsafe living conditions; and improving survival of middle-aged and older people due to chronic disease. The resulting increases in life expectancy (together with the lower birth rates that typically accompany socioeconomic development) mean that older people account for a larger proportion of the general population.11. World Health Organization. Good health adds life to years: Global brief for World Health Day 2012. Geneva; 2012. The extent of the resulting changes in population characteristics can be startling, especially for developing countries (Figure 1).
Changing age distribution in general population of China, 1990-2050. U.S Census Bureau, International Data Base
In contrast to the situation even two generations ago, people can expect to live for many years after the usual retirement age. For example, U.K men and women aged 65 years in 2030 can expect to live until age 88 and 91 years, respectively.44. Select committee on public service and demographic change. Ready for Aging? Report. London: House of Lords; 2013. Predicted life expectancy for today's children is controversial, but experts estimate that 50% of U.K children born in 2007 will live to at least 103 years.44. Select committee on public service and demographic change. Ready for Aging? Report. London: House of Lords; 2013. Although it is clear that people are living longer, it is uncertain how much of the increased life expectancy will translate into years of good health. These demographic changes have dramatic potential implications for conditions such as CKD, for which the prevalence increases with age.
CKD is common in older people and its prevalence increases in parallel with age
It has been known for decades that estimated glomerular filtration rate (eGFR) declines
in parallel with age.55. Davies DF, Shock NW. Age changes in glomerular filtration rate,
effective renal plasma flow, and tubular excretory capacity in adult males. J Clin
Invest 1950;29:496-507. DOI: http://dx.doi.org/10.1172/JCI102286
http://dx.doi.org/10.1172/JCI102286...
The prevalence of CKD
among females in the Chinese general population increases from 7.4% among those aged
18-39 years to 18.0% and 24.2% among those aged 60-69 and 70 years respectively.66. Zhang L, Wang F, Wang L, Wang W, Liu B, Liu J, et al. Prevalence of
chronic kidney disease in China: a cross-sectional survey. Lancet 2012;379:815-22.
DOI: http://dx.doi.org/10.1016/S0140-6736(12)60033-6
http://dx.doi.org/10.1016/S0140-6736(12)...
Relative increases in the prevalence of CKD with
age are equally striking for populations in the U.S, Canada and Europe,77. Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al.
Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038-47.
PMID: 17986697 DOI: http://dx.doi.org/10.1001/jama.298.17.2038
http://dx.doi.org/10.1001/jama.298.17.20...
8. Zhang QL, Rothenbacher D. Prevalence of chronic kidney disease in
population-based studies: systematic review. BMC Public Health 2008;8:117. PMID:
18405348 DOI: http://dx.doi.org/10.1186/1471-2458-8-117
http://dx.doi.org/10.1186/1471-2458-8-11...
-99. Arora P, Vasa P, Brenner D, Iglar K, McFarlane P, Morrison H, et al.
Prevalence estimates of chronic kidney disease in Canada: results of a nationally
representative survey. CMAJ 2013;185:E417-23. DOI:
http://dx.doi.org/10.1503/cmaj.120833
http://dx.doi.org/10.1503/cmaj.120833...
although there are between-country differences in the absolute
prevalence.
At older ages, an increased proportion of prevalent CKD cases has low eGFR alone (as
compared to albuminuria alone, or both low eGFR and albuminuria).1010. James MT, Hemmelgarn BR, Tonelli M. Early recognition and prevention
of chronic kidney disease. Lancet 2010;375:1296-309. PMID: 20382326 DOI:
http://dx.doi.org/10.1016/S0140-6736(09)62004-3
http://dx.doi.org/10.1016/S0140-6736(09)...
Although this might suggest that many older people with CKD can
expect lower rates of kidney function loss, available data are inconclusive - and
current knowledge does not allow clinicians to reliably distinguish between those whose
CKD will and will not progress.
As for other age groups, the incidence of dialysis-dependent kidney failure has steadily
increased among older people over the last few decades: in the U.S, a 57% age-adjusted
increase in the number of incident octogenarians and nonagenarians was noted between
1996 and 2003 alone.1111. Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and
nonagenarians starting dialysis in the United States. Ann Intern Med 2007;146:177-83.
PMID: 17283348 DOI:
http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006
http://dx.doi.org/10.7326/0003-4819-146-...
Despite this increase,
patients aged > 80 years are still less likely to initiate dialysis than those aged
75-79 years - although a large recent study suggested that the risk of developing very
low eGFR (< 15 ml/min/1.73 m2) is similar for older and younger
adults.1212. Hemmelgarn BR, James MT, Manns BJ, O'Hare AM, Muntner P, Ravani P,
et al. Rates of treated and untreated kidney failure in older vs younger adults. JAMA
2012;307:2507-15. PMID: 22797451 DOI:
http://dx.doi.org/10.1001/jama.2012.6455
http://dx.doi.org/10.1001/jama.2012.6455...
It is uncertain whether this
discrepancy is due to between-age differences in the true rate of progressive kidney
function loss, the risk of death due to competing causes, patient views about dialysis,
or physician practices.1212. Hemmelgarn BR, James MT, Manns BJ, O'Hare AM, Muntner P, Ravani P,
et al. Rates of treated and untreated kidney failure in older vs younger adults. JAMA
2012;307:2507-15. PMID: 22797451 DOI:
http://dx.doi.org/10.1001/jama.2012.6455
http://dx.doi.org/10.1001/jama.2012.6455...
,1313. Keith DS, Nichols GA, Gullion CM, Brown JB, Smith DH. Longitudinal
follow-up and outcomes among a population with chronic kidney disease in a large
managed care organization. Arch Intern Med 2004;164:659-63. DOI:
http://dx.doi.org/10.1001/archinte.164.6.659
http://dx.doi.org/10.1001/archinte.164.6...
Regardless of the explanation, the aging
population will likely lead to continued increases in the number of older people with
severe CKD.
CKD is harmful but treatable if patients at risk are identified
Like younger people, older people with advanced CKD are at increased risk of death,
kidney failure, myocardial infarction and stroke compared to otherwise similar people
with normal or mildly reduced eGFR.1414. Hemmelgarn BR, Manns BJ, Lloyd A, James MT, Klarenbach S, Quinn RR,
et al. Relation between kidney function, proteinuria, and adverse outcomes. JAMA
2010;303:423-9. PMID: 20124537 DOI:
http://dx.doi.org/10.1001/jama.2010.39
http://dx.doi.org/10.1001/jama.2010.39...
,1515. O'Hare AM, Bertenthal D, Covinsky KE, Landefeld CS, Sen S, Mehta K,
et al. Mortality risk stratification in chronic kidney disease: one size for all
ages? J Am Soc Nephrol 2006;17:846-53. Although death is by
far the most common of these adverse outcomes, this does not mean that older patients
with clinically relevant CKD cannot benefit from timely specialist referral.
With appropriate management, patients with advanced CKD (regardless of age) may benefit
from slower loss of kidney function (potentially preventing kidney failure), better
control of metabolic consequences such as acidosis, anemia and hyperphosphatemia, lower
risk of cardiovascular events, and (for those who are interested in renal replacement) a
more informed choice of renal replacement modality, including timely creation of
vascular access.1616. Stevens PE, Levin A.; Kidney Disease: Improving Global Outcomes
Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and
management of chronic kidney disease: synopsis of the kidney disease: improving
global outcomes 2012 clinical practice guideline. Ann Intern Med 2013;158:825-30.
DOI: http://dx.doi.org/10.7326/0003-4819-158-11-201306040-00007
http://dx.doi.org/10.7326/0003-4819-158-...
The aging population will
likely lead to continued increases in the number of older people who might require such
referral, which should be considered in assessments of future nephrology workforce
capacity.
Dialysis can benefit older people with kidney failure
In developed countries, the default management strategy for older people with kidney
failure appears to have shifted from conservative management to initiation of
dialysis.1717. Thorsteinsdottir B, Montori VM, Prokop LJ, Murad MH. Ageism vs. the
technical imperative, applying the GRADE framework to the evidence on hemodialysis in
very elderly patients. Clin Interv Aging 2013;8:797-807. DOI:
http://dx.doi.org/10.2147/CIA.S43817
http://dx.doi.org/10.2147/CIA.S43817...
On average, life expectancy after
initiation of dialysis is relatively short for older patients: median survival among
incident U.S dialysis patients aged 80-84 years is 16 months - and is only 12 months
among those aged 85-89 years.1111. Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and
nonagenarians starting dialysis in the United States. Ann Intern Med 2007;146:177-83.
PMID: 17283348 DOI:
http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006
http://dx.doi.org/10.7326/0003-4819-146-...
At the same time,
these median statistics reflect a bimodal distribution of survival time in older
dialysis patients: although a large proportion die within 6 months of commencing
dialysis, a substantial minority may live for years. This heterogeneity in mortality
appears to be driven by differences in baseline comorbidity. For example, analyses of a
small U.K cohort of people with advanced kidney failure suggested that initiation of
dialysis was not associated with increased survival for those aged > 75 and with two
or more comorbidities.1818. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN,
Farrington K. Survival of elderly patients with stage 5 CKD: comparison of
conservative management and renal replacement therapy. Nephrol Dial Transplant
2011;26:1608-14. DOI: http://dx.doi.org/10.1093/ndt/gfq630
http://dx.doi.org/10.1093/ndt/gfq630...
,1919. Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE.
Dialysis or not? A comparative survival study of patients over 75 years with chronic
kidney disease stage 5. Nephrol Dial Transplant 2007;22:1955-62. PMID: 17412702 DOI:
http://dx.doi.org/10.1093/ndt/gfm153
http://dx.doi.org/10.1093/ndt/gfm153...
Similarly, the presence of two to three comorbid
conditions in U.S. dialysis patients aged > 65 years was associated with
substantially increased mortality compared to those in better health.1111. Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and
nonagenarians starting dialysis in the United States. Ann Intern Med 2007;146:177-83.
PMID: 17283348 DOI:
http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006
http://dx.doi.org/10.7326/0003-4819-146-...
When functional status is lower at baseline,
initiation of dialysis often signals the onset of further declines: among 3702 nursing
home residents initiating dialysis, 58% had died and 87% had experienced additional loss
of function at 1 year.2020. Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS,
McCulloch CE. Functional status of elderly adults before and after initiation of
dialysis. N Engl J Med 2009;361:1539-47. PMID: 19828531 DOI:
http://dx.doi.org/10.1056/NEJMoa0904655
http://dx.doi.org/10.1056/NEJMoa0904655...
Although available data
have limitations, quality of life appears reasonable among selected older dialysis
patients - and can remain stable despite moderate or high levels of comorbidity.2121. Lamping DL, Constantinovici N, Roderick P, Normand C, Henderson L,
Harris S, et al. Clinical outcomes, quality of life, and costs in the North Thames
Dialysis Study of elderly people on dialysis: a prospective cohort study. Lancet
2000;356:1543-50. PMID: 11075766 DOI:
http://dx.doi.org/10.1016/S0140-6736(00)03123-8
http://dx.doi.org/10.1016/S0140-6736(00)...
,2222. Unruh ML, Newman AB, Larive B, Dew MA, Miskulin DC, Greene T, et
al.; Hemodialysis Study Group. The influence of age on changes in health-related
quality of life over three years in a cohort undergoing hemodialysis. J Am Geriatr
Soc 2008;56:1608-17. DOI:
http://dx.doi.org/10.1111/j.1532-5415.2008.01849.x
http://dx.doi.org/10.1111/j.1532-5415.20...
These data suggest that dialysis is an appropriate treatment option for well-informed older patients with kidney failure - especially for those with good baseline quality of life. On the other hand, the very poor outcomes experienced in those with more comorbidity or lower functional status at baseline clearly demonstrate that dialysis does not improve clinical outcomes for all older people with kidney failure - and that good clinical judgment and careful communication will be increasingly required as the general population continues to age.
Kidney transplantation can also benefit older people with kidney failure
It is generally accepted that older age alone does not preclude kidney transplantation
in otherwise suitable candidates. However, older patients with kidney failure are more
likely to have absolute and relative contraindications to transplantation, and are less
likely to be placed on the kidney transplantation waiting list. Unsurprisingly, patient
and graft 5-year survival probabilities are lower among U.S kidney transplant recipients
aged ≥ 65 years as compared to those aged 35-49 years (patient: 67.2%
vs. 89.6%; graft: 60.9% vs. 75.4%,
respectively).2323. Knoll GA. Kidney transplantation in the older adult. Am J Kidney Dis
2013;61:790-7. DOI: http://dx.doi.org/10.1053/j.ajkd.2012.08.049
http://dx.doi.org/10.1053/j.ajkd.2012.08...
In addition, older people who
are potential kidney transplant recipients face several potential disadvantages compared
to their younger counterparts (Chart 1).
Nonetheless, transplantation appears to reduce mortality among patients of all ages. For
example, among those aged 74 years, receiving a deceased donor transplant was associated
with a hazard ratio of mortality of 0.67 (95% confidence interval 0.53, 0.86) as
compared to remaining on dialysis.2323. Knoll GA. Kidney transplantation in the older adult. Am J Kidney Dis
2013;61:790-7. DOI: http://dx.doi.org/10.1053/j.ajkd.2012.08.049
http://dx.doi.org/10.1053/j.ajkd.2012.08...
Use of
expanded criteria deceased donors2424. Merion RM, Ashby VB, Wolfe RA, Distant DA, Hulbert-Shearon TE,
Metzger RA, et al. Deceased-donor characteristics and the survival benefit of kidney
transplantation. JAMA 2005;294:2726-33. PMID: 16333008 DOI:
http://dx.doi.org/10.1001/jama.294.21.2726
http://dx.doi.org/10.1001/jama.294.21.27...
,2525. Cohen B, Smits JM, Haase B, Persijn G, Vanrenterghem Y, Frei U.
Expanding the donor pool to increase renal transplantation. Nephrol Dial Transplant
2005;20:34-41. DOI: http://dx.doi.org/10.1093/ndt/gfh506
http://dx.doi.org/10.1093/ndt/gfh506...
as well as more
liberal use of older living donors2626. Gill J, Bunnapradist S, Danovitch GM, Gjertson D, Gill JS, Cecka M.
Outcomes of kidney transplantation from older living donors to older recipients. Am J
Kidney Dis 2008;52:541-52. PMID: 18653267 DOI:
http://dx.doi.org/10.1053/j.ajkd.2008.05.017
http://dx.doi.org/10.1053/j.ajkd.2008.05...
also appear
to reduce mortality among older people with kidney failure, as compared to similar
patients who remain on the transplant waiting list (Chart 2). These latter two strategies are especially appealing for use in
developing countries, where growth in the prevalence of older people has been most
pronounced. However, because transplant surgery itself temporarily increases the risk of
death, the mortality benefits associated with kidney transplantation (regardless of
donor type) are restricted to those with reasonable baseline life expectancy and without
dramatically increased perioperative risk.2727. Gill JS, Tonelli M, Johnson N, Kiberd B, Landsberg D, Pereira BJ.
The impact of waiting time and comorbid conditions on the survival benefit of kidney
transplantation. Kidney Int 2005;68:2345-51. PMID: 16221239 DOI:
http://dx.doi.org/10.1111/j.1523-1755.2005.00696.x
http://dx.doi.org/10.1111/j.1523-1755.20...
Research needs
Although much is known about chronic kidney disease in older populations, a great deal remains to be learned. Many trials of therapies for CKD have excluded older patients2828. O'Hare AM, Kaufman JS, Covinsky KE, Landefeld CS, McFarland LV, Larson EB. Current guidelines for using angiotensin-converting enzyme inhibitors and angiotensin II-receptor antagonists in chronic kidney disease: is the evidence base relevant to older adults? Ann Intern Med 2009;150:717-24. PMID: 19451579,2929. Mohanlal V, Weir M. Kidney transplantation in the elderly: it's not all gloom and doom. ASN Kidney News 2011;3:15-7. - and most do not provide guidance on how to manage comorbidities that often accompany CKD but may lead to competing therapeutic priorities. More information is needed on how to accurately identify people who will progress to kidney failure - and among these, the subset that can expect reasonable life expectancy and quality of life if they opt for dialysis treatment. Future studies should test new ways to communicate information about the risks and benefits of dialysis (as compared to conservative management), to facilitate informed patient decisions. Above all, we need more studies that demonstrate how to optimize quality of life and manage symptoms in elderly people with CKD - including those who have chosen conservative management.
The way forward
The aging of the general population means that older people now account for a much greater proportion of patients with or at risk for kidney disease and kidney failure. The tremendous clinical heterogeneity within this population indicates the need for more discerning management. Chronological age alone will not be sufficient as the basis for clinical decisions, and a more nuanced approach is required - based on the comorbidities, functional status, quality of life and preferences of each individual patient. Clinicians can be reassured that dialysis and kidney transplantation can increase life expectancy - and will allow reasonable quality of life in selected older people with kidney failure. Perhaps more importantly, clinicians, patients and their families can be comforted by the knowledge that timely specialist evaluation can help to improve outcomes and reduce symptoms in older people with advanced kidney disease - whether they have selected conservative management or dialysis as their treatment plan.
Acknowledgements
Dr. Tonelli was supported by a Government of Canada research chair in the optimal care of people with chronic kidney disease.
References
-
1World Health Organization. Good health adds life to years: Global brief for World Health Day 2012. Geneva; 2012.
-
2Wiener JM, Tilly J. Population ageing in the United States of America: implications for public programmes. Int J Epidemiol 2002;31:776-81. DOI: http://dx.doi.org/10.1093/ije/31.4.776
» http://dx.doi.org/10.1093/ije/31.4.776 -
3Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int 2011;80:1258-70. PMID: 21993585 DOI: http://dx.doi.org/10.1038/ki.2011.368
» http://dx.doi.org/10.1038/ki.2011.368 -
4Select committee on public service and demographic change. Ready for Aging? Report. London: House of Lords; 2013.
-
5Davies DF, Shock NW. Age changes in glomerular filtration rate, effective renal plasma flow, and tubular excretory capacity in adult males. J Clin Invest 1950;29:496-507. DOI: http://dx.doi.org/10.1172/JCI102286
» http://dx.doi.org/10.1172/JCI102286 -
6Zhang L, Wang F, Wang L, Wang W, Liu B, Liu J, et al. Prevalence of chronic kidney disease in China: a cross-sectional survey. Lancet 2012;379:815-22. DOI: http://dx.doi.org/10.1016/S0140-6736(12)60033-6
» http://dx.doi.org/10.1016/S0140-6736(12)60033-6 -
7Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038-47. PMID: 17986697 DOI: http://dx.doi.org/10.1001/jama.298.17.2038
» http://dx.doi.org/10.1001/jama.298.17.2038 -
8Zhang QL, Rothenbacher D. Prevalence of chronic kidney disease in population-based studies: systematic review. BMC Public Health 2008;8:117. PMID: 18405348 DOI: http://dx.doi.org/10.1186/1471-2458-8-117
» http://dx.doi.org/10.1186/1471-2458-8-117 -
9Arora P, Vasa P, Brenner D, Iglar K, McFarlane P, Morrison H, et al. Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey. CMAJ 2013;185:E417-23. DOI: http://dx.doi.org/10.1503/cmaj.120833
» http://dx.doi.org/10.1503/cmaj.120833 -
10James MT, Hemmelgarn BR, Tonelli M. Early recognition and prevention of chronic kidney disease. Lancet 2010;375:1296-309. PMID: 20382326 DOI: http://dx.doi.org/10.1016/S0140-6736(09)62004-3
» http://dx.doi.org/10.1016/S0140-6736(09)62004-3 -
11Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med 2007;146:177-83. PMID: 17283348 DOI: http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006
» http://dx.doi.org/10.7326/0003-4819-146-3-200702060-00006 -
12Hemmelgarn BR, James MT, Manns BJ, O'Hare AM, Muntner P, Ravani P, et al. Rates of treated and untreated kidney failure in older vs younger adults. JAMA 2012;307:2507-15. PMID: 22797451 DOI: http://dx.doi.org/10.1001/jama.2012.6455
» http://dx.doi.org/10.1001/jama.2012.6455 -
13Keith DS, Nichols GA, Gullion CM, Brown JB, Smith DH. Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Intern Med 2004;164:659-63. DOI: http://dx.doi.org/10.1001/archinte.164.6.659
» http://dx.doi.org/10.1001/archinte.164.6.659 -
14Hemmelgarn BR, Manns BJ, Lloyd A, James MT, Klarenbach S, Quinn RR, et al. Relation between kidney function, proteinuria, and adverse outcomes. JAMA 2010;303:423-9. PMID: 20124537 DOI: http://dx.doi.org/10.1001/jama.2010.39
» http://dx.doi.org/10.1001/jama.2010.39 -
15O'Hare AM, Bertenthal D, Covinsky KE, Landefeld CS, Sen S, Mehta K, et al. Mortality risk stratification in chronic kidney disease: one size for all ages? J Am Soc Nephrol 2006;17:846-53.
-
16Stevens PE, Levin A.; Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med 2013;158:825-30. DOI: http://dx.doi.org/10.7326/0003-4819-158-11-201306040-00007
» http://dx.doi.org/10.7326/0003-4819-158-11-201306040-00007 -
17Thorsteinsdottir B, Montori VM, Prokop LJ, Murad MH. Ageism vs. the technical imperative, applying the GRADE framework to the evidence on hemodialysis in very elderly patients. Clin Interv Aging 2013;8:797-807. DOI: http://dx.doi.org/10.2147/CIA.S43817
» http://dx.doi.org/10.2147/CIA.S43817 -
18Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant 2011;26:1608-14. DOI: http://dx.doi.org/10.1093/ndt/gfq630
» http://dx.doi.org/10.1093/ndt/gfq630 -
19Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007;22:1955-62. PMID: 17412702 DOI: http://dx.doi.org/10.1093/ndt/gfm153
» http://dx.doi.org/10.1093/ndt/gfm153 -
20Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009;361:1539-47. PMID: 19828531 DOI: http://dx.doi.org/10.1056/NEJMoa0904655
» http://dx.doi.org/10.1056/NEJMoa0904655 -
21Lamping DL, Constantinovici N, Roderick P, Normand C, Henderson L, Harris S, et al. Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study. Lancet 2000;356:1543-50. PMID: 11075766 DOI: http://dx.doi.org/10.1016/S0140-6736(00)03123-8
» http://dx.doi.org/10.1016/S0140-6736(00)03123-8 -
22Unruh ML, Newman AB, Larive B, Dew MA, Miskulin DC, Greene T, et al.; Hemodialysis Study Group. The influence of age on changes in health-related quality of life over three years in a cohort undergoing hemodialysis. J Am Geriatr Soc 2008;56:1608-17. DOI: http://dx.doi.org/10.1111/j.1532-5415.2008.01849.x
» http://dx.doi.org/10.1111/j.1532-5415.2008.01849.x -
23Knoll GA. Kidney transplantation in the older adult. Am J Kidney Dis 2013;61:790-7. DOI: http://dx.doi.org/10.1053/j.ajkd.2012.08.049
» http://dx.doi.org/10.1053/j.ajkd.2012.08.049 -
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Publication Dates
-
Publication in this collection
Jan-Mar 2014
History
-
Received
12 Dec 2013 -
Accepted
10 Jan 2014