In the United States we are currently experiencing the phenomenon of the “graying of America,” whereby the population is growing older and the proportion of those 65 years and older is rapidly increasing. Data from the U.S. Census Bureau predict that the number of individuals 65 years and older will double in the next 20 years. Most of this growth is happening in the “oldest old”—that is, 85 years and older. Among other challenges, the aging of the population brings the increasing burden of chronic disease conditions such as diabetes, hypertension, and heart disease (1), all of which
Diabetes mellitus is the most common cause of chronic kidney disease (CKD) and kidney failure (1). More than one quarter of the United States population over age 65 has diabetes (2), and 37 percent of them have an eGFR <60 mL/min/1.73 m2 (3).
Whether the decreased GFR is due to age-related decline or to diabetic kidney disease (see other articles in this issue), it affects the clearance of insulin and many diabetes medications and raises the risk of hypoglycemia (4). Hypoglycemia is the major barrier to achieving near-normal glycemia, which
Chronic kidney disease (CKD) is a prevalent disease in the United States that disproportionately affects the elderly. The national prevalence is approximately 15 percent and reaches nearly 50 percent in adults aged 70 years and older (1). CKD stages 1 and 2 are characterized by a GFR >60 mL/min/1.73 m2, and dose adjustments are usually indicated only for drugs that have a narrow therapeutic index, such as aminoglycosides and vancomycin. CKD stages 3, 4, and 5 are characterized by progressively lower GFR—30 to 59, 15 to 29, and <15 mL/min/1.73m2, respectively—and drug dose adjustment
“If you really want to do something, you’ll find a way. If you don’t, you’ll find an excuse.”
—Jim Rohn, American entrepreneur, author, and motivational speaker
Arguably, the biggest problem facing end-of-life decision making in elderly patients with advanced and end stage renal disease is that conversations about the end of life simply don’t happen often enough. In one survey of dialysis patients, fewer than 10 percent reported having a conversation about end-of-life issues with their nephrologist in the past year. Moreover, fewer than 10 percent reported that any physician had ever discussed prognosis with them (1). This
In the United States, chronic kidney disease (CKD)—defined by reduced GFR <60 mL/min per 1.73 m2, or presence of kidney damage—is very common in the elderly population. The prevalence of CKD is estimated to be 46.8 percent in those older than 70 years (1). However, the significance of reduced GFR in the elderly has been debated, and some suggest that reduced GFR is secondary to (expected) age-related changes in kidney function and is not evidence of true kidney disease. Regardless of the label, elderly patients with reduced levels of GFR are at higher risk for adverse
The United States ESRD population is aging. Patients over the age of 65 have the highest adjusted prevalence of ESRD (Figure 1) (1). As a result of these demographics, nephrology providers are now faced with the task of recognizing and treating not only the burdens of ESRD but also morbidities associated with geriatric syndromes (Table 1). Prognosis for the elderly encompasses survival as well as effects on quality of life (QOL), cognition, functional status, and time lost from being with family. Treatment choice and follow-up care should address these issues while considering the individual’s
Guity Farahmand, Carol Lee, and Kirsten L. Johansen
Hypertension remains a growing problem in our aging population. Recent data from the National Health and Nutrition Examination Survey (NHANES) estimate that almost one-third of the adult population meets the criteria for hypertension (1). Furthermore, the prevalence increases with age; 65 percent of individuals over the age of 60 are hypertensive. Approximately three-quarters of the population with diagnoses of hypertension require some form of pharmacologic therapy, and the percentage is as high as 82 percent among individuals over the age of 60.
The Framingham Heart Study helped to elucidate the expected trajectory of blood pressure in normotensive and
Although there has been an overall slowing of incident cases of ESRD in the United States during the past several years, the elderly population continues to have the highest incident rates of ESRD (1) (Figures 1 and 2). This has significant implications for transplant centers, which are seeing a continual increase in the age of potential transplant recipients coming for evaluation. The continuing accumulation of data on outcomes in these patients should better inform the risks and benefits of transplantation as therapy for ESRD compared with dialysis. Also, as regulations tighten with regard
One of the major challenges for today’s society is the growth of the elderly population. By 2030, the age segment over 65 years will have nearly doubled, and the incidence of multiple age-associated disorders is predicted to increase in parallel. Age-associated changes of the kidney are important not only because normal aging alters renal function, but also because of the high frequency of ESRD in the elderly population (1). Moreover, old kidneys perform poorly when they experience acute kidney injury or after transplantation (2, 3), highlighting one of the hallmarks of renal aging—its markedly
Patients’ access to specialized care before kidney failure develops varies significantly across the United States and among different racial groups. And perceived racial discrimination may have negative effects on kidney function.
Pre-ESRD nephrology care is crucial for optimizing the health of patients with this condition. How the United States and global kidney community ensure such care for the millions of people with kidney disease is crucial to stemming the disease’s growing prevalence.
One approach is to look at the adequacy of care patients receive in different parts of the country and then examine the reasons for discrepancies in care.