Tratamiento renal conservador en ancianos con enfermedad renal crónica avanzada

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Abstract

Resumen Fundamento: Los resultados en salud del tratamiento renal sustitutivo (TRS) en el anciano han hecho que el tratamiento renal conservador (TRC) sea una opción terapéutica en la enfermedad renal crónica avanzada. Sin embargo, se sabe poco sobre la evolución de estos pacientes, por lo que el objetivo fue analizar la supervivencia de los pacientes ancianos en TRS y TRC y evaluar el efecto de las variables relacionadas con el inicio de ambos tratamientos. Método: Estudio de cohortes prospectivo de pacientes >75 años en TRS y TRC. Se realizó un análisis de supervivencia incluyendo la valoración de la función renal y variables demográficas y clínicas, comorbilidad, fragilidad y situación funcional, cognitiva, nutricional y social. Resultados: Cohorte de 37 pacientes en TRS y 82 en TRC. Los pacientes en TRC eran significativamente más ancianos, con mayor frecuencia de evento vascular, mayor comorbilidad (Charlson>8), peor situación funcional (Barthel), mayor riesgo de deterioro cognitivo (Pfeiffer) y malnutrición (MNA-SF), y mayor fragilidad y deterioro sociofamiliar. La tasa de mortalidad fue inferior en pacientes en TRS (8,7 vs 23/1.000 pacientes-mes; HR= 0,37; p=0,018) pero el ajuste por los diferentes síndromes geriátricos analizados redujo considerablemente esta ventaja de supervivencia. Conclusiones: La comorbilidad medida por el índice de Charlson fue predictor independiente de mortalidad en pacientes ancianos con enfermedad renal crónica avanzada. En aquellos pacientes ancianos con Charlson mayor de 8 puntos el TRS no mejoró la supervivencia respecto del TRC

Translated abstract

Abstract Background: The poor health outcomes of Renal Replacement Therapy (RRT) in the elderly has promoted Conservative Management (CM) as a therapeutic option in advanced chronic kidney disease. However, there is still a lack of evidence about prognosis of these patients; thus, the aim was to analyze the survival rate of elderly patients under CM and RRT and evaluate the variables related to the initiation of such treatments in clinical practice. Methods: Prospective cohort study of RRT and CM patients older than 75 years. Renal function parameters and geriatric assessments were carried out. This evaluation included: analysis of comorbidity, functional, cognitive, frailty, nutritional and socio-family status. Results: Cohort of 37 RRT and 82 CM patients. CM patients were significantly older, with more frequency of history of vascular event, more comorbility (Charlson), worse functional situation (Barthel), higher risks of cognitive impairment (Pfeiffer) and malnutrition (MNA-SF), and higher frailty and socio-familiar impairment. Mortality rate was lower in RRT patients (8.72 vs. 3/1,000 patients/month; HR= 0.37, p=0.018), but survival advantage reduced drastically after adjustment for the different geriatric syndromes analyzed. Conclusions: Charlson’s comorbidity was found to be an independent mortality predictor in elderly patients with advanced chronic kidney disease. Dialysis did not improve survival with respect to conservative treatment in patients with Charlson higher than 8 points.

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A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans.

John E. Morley, T Malmstrom, D Miller (2012)

To validate the FRAIL scale. Longitudinal study. Community. Representative sample of African Americans age 49 to 65 years at onset of study. The 5-item FRAIL scale (fatigue, resistance, ambulation, illnesses, and loss of weight), at baseline and activities of daily living (ADLs), instrumental activities of daily living (IADLs), mortality, short physical performance battery (SPPB), gait speed, one-leg stand, grip strength and injurious falls at baseline and 9 years. Blood tests for CRP, SIL6R, STNFR1, STNFR2 and 25 (OH) vitamin D at baseline. Cross-sectionally the FRAIL scale correlated significantly with IADL difficulties, SPPB, grip strength and one-leg stand among participants with no baseline ADL difficulties (N=703) and those outcomes plus gait speed in those with no baseline ADL dependencies (N=883). TNFR1 was increased in pre-frail and frail subjects and CRP in some subgroups. Longitudinally (N=423 with no baseline ADL difficulties or N=528 with no baseline ADL dependencies), and adjusted for the baseline value for each outcome, being pre-frail at baseline significantly predicted future ADL difficulties, worse one-leg stand scores, and mortality in both groups, plus IADL difficulties in the dependence-excluded group. Being frail at baseline significantly predicted future ADL difficulties, IADL difficulties, and mortality in both groups, plus worse SPPB in the dependence-excluded group. This study has validated the FRAIL scale in a late middle-aged African American population. This simple 5-question scale is an excellent screening test for clinicians to identify frail persons at risk of developing disability as well as decline in health functioning and mortality.

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Functional status of elderly adults before and after initiation of dialysis.

Manjula Kurella Tamura, Kenneth E. Covinsky, Glenn Chertow … (2009)

It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD). Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty). The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis. Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status. 2009 Massachusetts Medical Society