The increasing number of older patients with renal disease

“Are my kidneys going to wear out before the rest of me?” is a valid question for older patients with hypertension and a raised serum creatinine concentration. The extent of the problem is illustrated by a study in an inner London primary healthcare setting.¹ In the age group 50-75 years, the prevalence of renal impairment (serum creatinine higher than 120 μmol/l) was 6.1% in patients known to have hypertension, 12.6% in those known to have diabetes, and 16.9% in those with both.¹ Many of these patients will progress to end stage renal failure. Of the one million patients who need chronic dialysis worldwide, more than half are over 65 years, as are approximately 10% of patients waiting for cadaveric transplants. (www.uktransplant.org.uk) The renal registry report for the United Kingdom for 2002 indicates the acceptance rate for dialysis for patients over 65 is approaching 300 patients per 1 000 000 population, compared with 72 per 1 000 000 population in those aged 18-64 years.²

Many of these patients will progress to end stage renal failure. Of the one million patients who need chronic dialysis worldwide, more than half are over 65 years, as are approximately 10% of patients waiting for cadaveric transplants.² The renal registry report for the United Kingdom for 2002 indicates the acceptance rate for dialysis for patients over 65 is approaching 300 patients per 1 000 000 population, compared with 72 per 1 000 000 population in those aged 18-64 years. The national service framework for older people has recently been published, and the national service framework for renal services is awaited. It is becoming increasingly clear that for many patients themes and standards from both of these frameworks will apply.

The “giants of geriatrics”—immobility, instability, incontinence, intellectual impairment³—with the addendum of iatrogenic disease, are challenges that may confront some older patients. In patients facing end stage renal failure these difficulties will have implications for choices of renal replacement, tolerance to treatment, and quality of life. The problem of instability and the potential subsequent falls may be an illustration of this. There are abundant reasons why older people with renal failure might be more vulnerable than those without it. Impaired mobility secondary to the myopathy of vitamin D insufficiency⁴ and β₂ microglobulin arthropathy could affect postural stability and potentially increase the risk of falls. Diabetes is the primary renal disease in up to 20% of patients over 65 years,² and diabetes related sensory neuropathy, autonomic neuropathy, and visual impairment can endanger postural stability. In addition the cardiovascular burden in the dialysis population is vast: 80% of patients starting dialysis have some left ventricular abnormality, often exacerbated by factors such as extensive vascular calcification, anaemia, fluid overload, and myocardial fibrosis. These factors may increase susceptibility to orthostatic hypotension during and between two dialysis sessions, which could contribute to falls. Polypharmacy and depression, both prevalent in patients with end stage renal failure,⁵ are known risk factors for falls. These and other factors affecting postural stability occur against a background of evolving renal osteodystrophy and risk factors for osteoporosis.⁶,⁷ This may start to explain the alarming statistics, which imply that, compared with age, race, and sex matched controls, patients with end stage renal failure have a 4.4 increased relative risk for hip fracture, and resulting mortality at one year is two and a half times greater.⁸

In the 1970s and 1980s older patients were not routinely offered dialysis. This ageist practice was partly a resource issue but may have also been based in the false presumption that older patients would not benefit from kidney replacement. It is now clear that age alone should be no contraindication to dialysis and that good outcomes can be achieved.⁹,¹⁰ It is the responsibility of nephrologists to communicate this so that renal services are not rationed on the basis of age at point of referral. Older patients who would opt for dialysis can then receive this treatment electively after counselling and optimisation of their uraemic syndromes or any comorbidity.

Although renal replacement is now part of our medical landscape, it remains an aggressive tertiary intervention that may challenge the priorities and attitudes of older patients in particular. Dialysis also has hazards, and in some patients it will shorten life. Some advanced or unstable comorbidities will negatively affect prognosis, and this requires clear explanation to the patient and their family. The patient's preference and quality of life are central issues. When dialysis is not considered appropriate, the nephrologist should continue to play an active part in slowing progression of the renal failure, including achieving control of blood pressure, treating anaemia, and controlling uraemic symptoms. In such cases it is particularly important that the nephrologist works with geriatricians, general practitioners, and, when appropriate, specialist renal palliative care services to optimise medical treatment, manage symptoms, and maintain wellbeing and functional independence whenever possible.

The national service framework for older people emphasises person centred care delivered by staff who have the right set of skills to meet their patients' needs, and this is an obligation for any medical professional providing care to older patients. The challenge is to develop models of care integrating nephrology and geriatric medicine. Specialist geriatric nephrology units have been advocated as one way forward,¹¹ but in this relatively small specialty these divisive approaches may be counterproductive. We believe that it would be more beneficial to integrate the expertise of the nephrologist with the skills of those trained in the care of older people. Nephrology training programmes must reflect the changing demographics of patients with renal disease. Trainees in nephrology should enhance their skills with a working knowledge of geriatric medicine, including functional, psychological, and social considerations and incorporating the “comprehensive geriatric assessment” approach practised by geriatricians. In the United States the renal training programme director's committee has already liaised with the American Geriatrics Society to consider a suitable core curriculum and has discussed the potential for fellowships in nephrology-geriatric medicine.¹²

The rapidly expanding group of older nephrology patients is a positive reflection of recent developments in medical care and offers an opportunity to establish links between nephrology and geriatric medicine. Embracing these changes with a positive, forward looking attitude will open up a rewarding new field of clinical practice and many diverse research opportunities. Ultimately this can only improve the services we offer to our patients.