Guidelines and the Older Patient with CKD
Geriatric patients with CKD are at high risk from the potential side effects of treatments.
Editor's note: Dr. Rifkin, together with Mark Sarnak, MD, and Paul Stevens, MD, will participate in a session on this topic during presentations at the National Kidney Foundation 2014 Spring Clinical Meetings, April 22-26, at the MGM Grand in Las Vegas.
Geriatric patients with chronic kidney disease (CKD) are at high risk for morbidity and mortality not only from their underlying diseases, but also from the potential side effects of treatments. Often, treatment decisions need to be individualized, taking into account a patient's preferences, comorbidities, life expectancy, and quality of life.
This is a heterogeneous population in which a healthy and active 80-year-old with CKD 3A is quite different from a chronically ill 80-year-old with CKD 5. While the former patient may live to see the benefit of a given treatment, the latter patient may be more likely to be harmed by its adverse effects.
Thus, crafting unified comprehensive practice guidelines is often difficult, and it is made more problematic by the fact that this population tends to be under-represented in trials that serve as a basis for guidelines.
This article will illustrate some of the challenges with integrating potentially incomplete and conflicting guidelines into clinical practice.
Although hypertension is highly prevalent in elderly patients with CKD and contributes to significant cardiovascular morbidity and mortality, its optimal management in this population is unknown. Most of the available data have been extrapolated either from studies of younger populations with CKD or elderly populations without advanced CKD.
The 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines on hypertension concluded that there is insufficient evidence to recommend any particular blood pressure (BP) goals in the elderly with CKD. Instead, a general recommendation was made to individualize therapy while carefully considering comorbidities and potential side effects, such as orthostatic hypotension.
The guidelines also recommended that clinicians take into account the deleterious effects on quality of life that pharmacotherapy and certain lifestyle interventions, such as strict sodium restriction, may have.
More recently, members of the Eighth Joint National Committee (JNC 8) published their 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults in which they discussed treatment of hypertension in the CKD and elderly populations.1
They provided a recommendation to treat hypertension to a goal of less than 150/90 mmHg in those older than 60 years and found no evidence that lower BP goals in this population are beneficial. In contrast, for patients with diabetes or CKD aged 18-70 years, a goal BP of less than 140/90 was recommended based on expert opinion. No specific recommendations were made for patients aged 70 years or older with a glomerular filtration rate less than 60 mL/min/1.73m2 based on a lack of outcomes data in this population.
However, there was dissent among panel members, reflecting uncertainty even in the expert community;2 the ongoing multicenter Systolic Blood Pressure Intervention Trial (SPRINT), which encompasses a large proportion of patients with CKD and advanced age, hopefully will shed more light on this topic, although its intensive arm (less than 120 mm Hg systolic BP) is less than either of the debated targets by the members of the JNC committee.
Diabetes and CKD often coexist and impart a very high risk for cardiovascular disease. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) issued an update to their diabetes guidelines in 2012, recommending a goal hemoglobin A1C of 7% for diabetics with CKD. However, they suggested that goals may be liberalized for those who are at risk for hypoglycemia, have comorbidities, or a limited life expectancy.
Furthermore, it has been hypothesized that elderly patients with a long duration of diabetes (more than 15 years) and established atherosclerosis are less likely to benefit from intensive glucose control.3
Thus, the American Diabetes Association, in conjunction with the American Geriatrics Society, provided more specific A1C goals in the elderly based on patient characteristics: less than 7.5% in healthy people with long life expectancies, less than 8.0% in those with moderate comorbidities and intermediate life expectancies, and less than 8.5% in those with multiple comorbidities and short life expectancies. Preference was also given to drug regimens that avoid imposing an undue burden on patients or their caretakers while minimizing adverse effects