Lipids

Both KDOQI and the ADA recommend LDL lowering with statins in patients with CKD and diabetes who are not yet on dialysis.  The cardiovascular benefit from statins in the elderly has been observed within just 3.5 ± 1.5 years of follow-up in meta-analysis.3 The SHARP study also demonstrated improved cardiovascular outcomes with LDL lowering in patients with an average age of 62 and eGFR of 26 mL/min/1.73 m2, lending support to their usage in older patients with CKD.

However, multiple studies have not shown statins to have a beneficial cardiovascular effect in ESRD populations. Furthermore, side effects, such as myopathy, may be more common in the elderly and should be monitored.

Anemia

For anemia management in CKD, KDIGO recommends that erythropoietin-stimulating agent (ESA) therapy should be initiated in dialysis patients and considered in pre-dialysis patients with Hb levels below 10 g/dL and should be avoided when Hb levels are above 11.5 g/dL.


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They further recommend individualizing these choices based on the risks of ESA therapy and the degree of anemia symptoms. There are no specific data on optimal hemoglobin levels in the elderly with CKD. Yet, prior studies have shown an improvement in quality of life with ESA usage in this population.5

Vascular Access

KDOQI recommends the placement of an arteriovenous (AV) fistula for initiation of dialysis, but the benefit of AV fistulas over AV grafts may not be realized in all elderly patients. AV fistulas are associated with longer maturation times and higher primary failure rates in the elderly, leading to additional procedures and an increased time using a catheter.

For certain patients, an AV graft may be a more optimal choice, and certain studies have shown similar mortality outcomes compared with AV fistulas in the elderly.6 As with most treatments in this population, a patient’s comorbidities and life expectancy should be taken into account when considering the type and timing of access placement.

Dr. Beben is a geriatrician and is currently a nephrology fellow at the University of California, San Diego. Dr. Rifkin is a nephrologist who is an Assistant Professor of Medicine at the University of California San Diego and an attending physician at the Veterans’ Affairs Medical Center in San Diego.

References

  1. James PA, Oparil S. Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013 Epub ahead of print.
  2. Wright Jr, JT, Fine LJ, Lackland DT, et al. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: The minority view. Ann Intern Med 2014 (Epub ahead of print).
  3. Sue Kirkman M, Brisco VJ, Clark N, et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc 2012;60:2342–2356.
  4. Savarese G, Gotto AM Jr, Paolillo S, et al. Benefits of statins in elderly subjects without established cardiovascular disease: A meta-analysis. J Am Coll Cardiol 2013;62:2090–2099.
  5. Moreno F, Aracil FJ, Pérez R, Valderrábano F. Controlled study on the improvement of quality of life in elderly hemodialysis patients after correcting end-stage renal disease-related anemia with erythropoietin. Am J Kidney Dis 1996;27:548–556.
  6. DeSilva RN, Patibandla BK, Vin Y, et al. Fistula first is not always the best strategy for the elderly. J Am Soc Nephrol  2013;24:1297–1304.