Clinical Practice Guideline on management of older ...
Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher eGFR<45ml/min/1.73m2): A summary document from the European Renal Best Practice Group.European Renal Best Practice Guideline Development GroupKen Farrington, Co-chair. Consultant Nephrologist, Renal Unit, Lister Hospital, Stevenage, Hertfordshire, UK.Adrian Covic, Co-Chair. Consultant nephrologist, Clinic of Nephrology, C. I. Parhon University Hospital, Gr T. Popa, University of Medicine and Pharmacy, Iasi, Romania. Ionut Nistor. Ionut Nistor: Consultant nephrologist, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania. Fillipo Aucella. Consultant nephrologist, Nephrology and Dialysis Unit at the Research Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy. Naomi Clyne. Consultant nephrologist, Sk?ne University Hospital, Lund, Sweden.Leen De Vos. Resident Nephrologist, Department of Nephrology, Ghent University Hospital, Ghent Belgium. Andrew Findlay. Consultant nephrologist, Lister Hospital, Stevenage UK. Denis Fouque. Consultant nephrologist, Division of nephrology, Université de Lyon, UCBL, INSERM, Centre Hospitalier Lyon Sud, Pierre Benite, France. Tomasz Grodzicki. Consultant Geriatrician, Department of Internal Medicine and Geriatrics, University Hospital of Krakow, Poland. Osasuyi Iyasere. Specialist registrar, Renal Unit, Leicester Royal Infirmary, UK. Kitty J. Jager. Epidemiologist, director of the ERA-EDTA registry, Department of Medical Informatics, Amsterdam Medical Center, Amsterdam, the Netherlands. Hanneke Joosten. Consultant nephrologist and geriatrician, Department of internal medicine, Maastricht University Medical Centre, Maastricht, the Netherlands. Juan Florencio Macias. Consultant geriatrician Faculty of Medicine, University of Salamanca, Salamanca, Spain. Andrew Mooney. Consultant nephrologist, Renal Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK. Evi Nagler. Consultant Nephrologist, Renal Division, Ghent University Hospital, Ghent, Belgium. Dorothea Nitsch. London School of Hygiene & Tropical Medicine, London, United Kingdom UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, London, United Kingdom. Maarten Taal. Consultant Nephrologist, Department of Renal Medicine, Royal Derby Hospital, Derby, UK Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK. James Tattersall. Consultant nephrologist, Leeds Teaching Hospitals Trust, Leeds, UK. Marijke Stryckers. Resident nephrologist, department of nephrology, Ghent University Hospital, Ghent, Belgium.Dieneke van Asselt. Consultant geriatrician, Department of Geriatric Medicine of the Radboud University Medical Center, Nijmegen,The Netherlands. Nele Van den Noortgate. Consultant geriatrician, Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium. Sabine van der Veer. Implementation Specialist, Centre for Health Informatics, University of Manchester, Manchester, United Kingdom. Wim van Biesen, (chair of ERBP): Consultant nephrologist, Renal Division, Ghent University Hospital, Ghent, Belgium IntroductionDespite the growing number of frail and older patients with eGFR<45ml/min/1.73m?, most studies still exclude this population, so providing guidance on best practice in this setting remains problematic. Nevertheless there is a clear need to support patients, their families and healthcare professionals with evidence based guidance to enhance the quality of patient care and experience and to establish a transparent framework for service provision and development. A joint initiative of the European Renal Association-European Dialysis Transplant Association (ERA-EDTA) and the European Union Geriatric Medicine Society (EUGMS) was established to address this issue. Expert groups were set up to scope the project, prioritize topics, search the literature, critically examine the evidence and produce recommendations. The methods used have been fully described PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkVSQlA8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA [1-3]. The current document summarises the main recommendations and their underlying rationales. The full guideline is freely available online and on the website of ERBP (european-renal-best- ) ADDIN REFMGR.CITE <Refman><Cite><Author>ERBP</Author><Year>2016</Year><RecNum>2</RecNum><IDText>Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR<45ml/min): </IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>2</Ref_ID><Title_Primary><f name="Calibri">Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR<45ml/min)</f><f name="Calibri"><b>: </b></f></Title_Primary><Authors_Primary>ERBP</Authors_Primary><Date_Primary>2016</Date_Primary><Reprint>Not in File</Reprint><Periodical>Nephrology, Dialysis, Transplantation</Periodical><ZZ_JournalFull><f name="System">Nephrology, Dialysis, Transplantation</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[1]. In the following sections we have used the term “older” to refer to people aged over 65 years.Proposed management pathway for older patients with advanced CKD (eGFR<45ml/min/1.73m2): (flow chart 1)Not all older patients with an eGFR<45ml/min/1.73m2 should be labelled as having kidney disease, since this may be part of physiological aging. Even for these patients however, awareness of eGFR is important for adjusting drug doses. Measurement of renal function in the older people has been considered in Question 1. Use of an estimation equation, taking into account potential sources of bias, such as underlying sarcopenia and/or malnutrition, is recommended. Deciding which older patients with advanced CKD may benefit from closer nephrological follow-up requires consideration of factors including the likelihood of progression of CKD (considered in Question 2) and the probability of survival to end-stage (considered in Question 3). The guideline development group considers that the Kidney Failure Risk Equation score PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlRhbmdyaTwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [4;5] provides reasonable predictions of the risk of progression of kidney failure in older patients. Management options for those with a low predicted progression should focus on nephroprotection rather than preparation for dialysis or conservative care. The Bansal score PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJhbnNhbDwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [6] was considered to provide acceptable risk prediction of mortality in this setting. For those with a high Bansal score – i.e. at high risk of dying, management should focus on advance care planning and on nephroprotection, if considered appropriate. Since the Bansal score was developed in cohorts with a low prevalence of frailty, in those patients with low Bansal scores, frailty should be formally assessed, and if present the patient should be considered at higher risk and managed accordingly. For patients with a high predicted risk for progression and with a low predicted risk for mortality, and in all cases of clinical equipoise, a shared decision approach should consider options for renal replacement therapy and conservative management (considered in Question 6). The REIN score ADDIN REFMGR.CITE <Refman><Cite><Author>Couchoud</Author><Year>2015</Year><RecNum>50</RecNum><IDText>Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>50</Ref_ID><Title_Primary>Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease</Title_Primary><Authors_Primary>Couchoud,C.G.</Authors_Primary><Authors_Primary>Beuscart,J.B.</Authors_Primary><Authors_Primary>Aldigier,J.C.</Authors_Primary><Authors_Primary>Brunet,P.J.</Authors_Primary><Authors_Primary>Moranne,O.P.</Authors_Primary><Date_Primary>2015/11</Date_Primary><Keywords>Aged</Keywords><Keywords>epidemiology</Keywords><Keywords>mortality</Keywords><Keywords>Prognosis</Keywords><Keywords>Renal Replacement Therapy</Keywords><Keywords>Risk</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>1178</Start_Page><End_Page>1186</End_Page><Periodical>Kidney Int.</Periodical><Volume>88</Volume><Issue>5</Issue><Misc_3>S0085-2538(15)61002-X [pii];10.1038/ki.2015.245 [doi]</Misc_3><Address>REIN Registry, Agence de la biomedecine, Saint-Denis la Plaine, France
Department of Biostatistics, EA2694, Lille School of Medicine, Lille2 University, Lille, France
Geriatric Department, University Hospital, Lille, France
Nephrology Unit, Dupuytren University Hospital, Limoges, France
Nephrology Unit, APHM University Hospital, Marseille, France
Nephrology Unit, Caremeau University Hospital, Nimes, France
Biostatistics, Epidemiology and Public Health, Institut Universitaire de Recherche Clinique, University of Montpellier, Montpellier, France</Address><Web_URL>PM:26331408</Web_URL><ZZ_JournalStdAbbrev><f name="System">Kidney Int.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[7] provides a reasonable estimate of short-term mortality risk should dialysis be commenced.Older patients with advanced CKD (eGFR<45ml/min/1.73m2) should be regularly screened for functional impairment (considered in Question 4) and malnutrition (considered in Question 5) to identify those likely to benefit from more in depth assessment and intervention. Interventions to improve nutritional and functional status were evaluated and recommendations formulated.Q1: What parameter should be used in older patients (a) to estimate kidney function (b) for dose adaptation purposes?1.1 We recommend using estimating equations which correct for differences in creatinine generation rather than plain serum creatinine measurements to assess kidney function in older patients (1A)1.2 We recommend that there is insufficient evidence to prefer one estimating equation over another since all perform equally and substantial misclassification can occur with any of these equations when used in older patients with differing body composition (1B). 1.3 We recommend formal measurement of kidney function if more accurate and precise estimation of GFR is required (1B). We suggest use of CKD-EPICr-Cys may be an acceptable alternative (2C)1.4 We recommend taking account of kidney function when prescribing drugs whose active forms or metabolites are renally cleared (1A)1.5 We suggest that for drugs with a narrow toxic/therapeutic range, regular measurement of serum concentrations can provide useful information. Differences in protein binding in relation to uraemia may necessitate use of different target levels of total drug concentration. (2C)Advice for clinical practiceKidney function can vary over time and should be monitored serially using the same equationEstimating equations can not be reliably used in patients with acute changes in kidney functionUse of different equations, even if well established, can result in different classifications of CKD stage for the same creatinine value from the same patient Serum levels of drugs depend upon absolute rather than body size corrected clearance.Formulae other than Cockcroft and Gault return eGFR, already corrected for body surface area (BSA) in units of ml/min/1.73m2. Drug dosing requires adjustment in proportion to absolute clearance in units of ml/min. To convert eGFR to absolute clearance, multiply eGFR by BSA/1.73. RationaleMethods to accurately assess true GFR (Cr-EDTA, Inulin clearance or Tc-DPTA) are impractical for use in routine clinical practice. Various formulae, either based on creatinine and/or cystatin, are in widespread use but there is no consensus about which formula should be used in older patients with advanced CKD. As aging is associated with declining GFR, but also with reduced creatinine generation due to loss of muscle mass, reduced physical activity, and decreased food intake, recommendations for the general population cannot necessarily be extrapolated to this subgroup. In addition, use of prescription drugs also tends to be high in older patients with advanced CKD. CKD management, referral practices, and safe use of renally excreted drugs, may be compromised if renal function is incorrectly estimated. Evidence suggests that, though serum creatinine concentration alone is insufficient to allow correct estimation of GFR in older people without some correction for creatinine generation, none of the established formulae consistently outperforms the others. Substantial reclassification in CKD stages has been demonstrated when different formulae are used to correct the same patient’s serum creatinine estimate. Relative performance is influenced by the methodology of creatinine measurement and the case-mix of the cohort (age, CKD stage and prevalence of frailty). If more exact knowledge of kidney function is sought, formal GFR measurement should be considered, though such testing may be laborious and expensive. Use of the CKD-Epicr-cys equation may be a useful alternative since this may improve the eGFR estimate. For drugs or their active drug metabolites that are cleared by the kidneys, dosing should be adapted to renal function. Hypoalbuminemia associated with malnutrition/inflammation and uraemia-related changes in protein binding may increase serum levels of the unbound (active) form of some drugs, which may require lower total concentrations to be targeted. Q2 What is the most reliable Risk Model Score to predict progression of chronic kidney disease in older patients with advanced CKD (eGFR < 45ml/min/1.73m2)?We recommend that the 4-variable Kidney Failure Risk Equation performs sufficiently well for use in older patients with advanced CKD and eGFR<45ml/min/1.73m2 (1B).RationaleThe purpose of this question is to provide guidance to clinicians on how best to estimate the risk of progression of CKD to end-stage kidney disease (ESKD) in older patients. This is important because the prevalence of CKD increases sharply with age PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNvcmVzaDwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [8] such that almost 50% of people aged over 70 years have CKD stage 3-5, though only a minority progress to ESKD PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkhhbGxhbjwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [12] and rapid decline may occur due to relatively unpredictable episodes of acute kidney injury (AKI) ADDIN REFMGR.CITE <Refman><Cite><Author>Coca</Author><Year>2012</Year><RecNum>40</RecNum><IDText>Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>40</Ref_ID><Title_Primary>Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis</Title_Primary><Authors_Primary>Coca,S.G.</Authors_Primary><Authors_Primary>Singanamala,S.</Authors_Primary><Authors_Primary>Parikh,C.R.</Authors_Primary><Date_Primary>2012/3</Date_Primary><Keywords>Acute Kidney Injury</Keywords><Keywords>Chronic Disease</Keywords><Keywords>Cohort Studies</Keywords><Keywords>complications</Keywords><Keywords>epidemiology</Keywords><Keywords>Glomerular Filtration Rate</Keywords><Keywords>Hospitalization</Keywords><Keywords>Humans</Keywords><Keywords>Incidence</Keywords><Keywords>Kidney</Keywords><Keywords>Kidney Diseases</Keywords><Keywords>Kidney Failure,Chronic</Keywords><Keywords>mortality</Keywords><Keywords>Risk Factors</Keywords><Keywords>Survival Rate</Keywords><Reprint>Not in File</Reprint><Start_Page>442</Start_Page><End_Page>448</End_Page><Periodical>Kidney Int.</Periodical><Volume>81</Volume><Issue>5</Issue><User_Def_5>PMC3788581</User_Def_5><Misc_3>S0085-2538(15)55323-4 [pii];10.1038/ki.2011.379 [doi]</Misc_3><Address>Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA</Address><Web_URL>PM:22113526</Web_URL><ZZ_JournalStdAbbrev><f name="System">Kidney Int.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[13] to which older people are at greater risk. It is also important to consider the competing risk of death in older people. In those aged 65 years and more, the risk of ESKD exceeds that of death only in those with eGFR<15ml/min/1.73m2 ADDIN REFMGR.CITE <Refman><Cite><Author>O'Hare</Author><Year>2007</Year><RecNum>41</RecNum><IDText>Age affects outcomes in chronic kidney disease</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>41</Ref_ID><Title_Primary>Age affects outcomes in chronic kidney disease</Title_Primary><Authors_Primary>O'Hare,A.M.</Authors_Primary><Authors_Primary>Choi,A.I.</Authors_Primary><Authors_Primary>Bertenthal,D.</Authors_Primary><Authors_Primary>Bacchetti,P.</Authors_Primary><Authors_Primary>Garg,A.X.</Authors_Primary><Authors_Primary>Kaufman,J.S.</Authors_Primary><Authors_Primary>Walter,L.C.</Authors_Primary><Authors_Primary>Mehta,K.M.</Authors_Primary><Authors_Primary>Steinman,M.A.</Authors_Primary><Authors_Primary>Allon,M.</Authors_Primary><Authors_Primary>McClellan,W.M.</Authors_Primary><Authors_Primary>Landefeld,C.S.</Authors_Primary><Date_Primary>2007/10</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Age Factors</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Glomerular Filtration Rate</Keywords><Keywords>Humans</Keywords><Keywords>Incidence</Keywords><Keywords>Kidney</Keywords><Keywords>Kidney Failure,Chronic</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>mortality</Keywords><Keywords>United States</Keywords><Reprint>Not in File</Reprint><Start_Page>2758</Start_Page><End_Page>2765</End_Page><Periodical>J.Am.Soc.Nephrol.</Periodical><Volume>18</Volume><Issue>10</Issue><Misc_3>ASN.2007040422 [pii];10.1681/ASN.2007040422 [doi]</Misc_3><Address>Department of Medicine, University of Washington, VA Puget Sound Healthcare System, Division of Nephrology, Building 100 Room 5B113, 1660 S. Columbian Way, Seattle, WA 98108, USA. ann.ohare@</Address><Web_URL>PM:17855638</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Am.Soc.Nephrol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[14]. Hence identification of the majority who are at low risk of progression could avoid the morbidity and stress associated with unnecessary interventions in preparation for RRT. Older people are often excluded from studies to evaluate nephroprotective interventions or develop risk prediction scores for CKD, so it is not clear whether scores developed in younger people will perform adequately well in older people.We found that the 4-variable Kidney Failure Risk Equation developed by Tangri et al PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlRhbmdyaTwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [4;5] performed well in younger and older groups, was well-validated and we recommend it for clinical use. A correction factor may need to be applied in non-North American populations. The 8-variable score performed only marginally better than the 4-variable. Only basic demographic and laboratory data are required for the 4-variable score, enabling a risk estimate to be generated automatically by laboratory computer systems. Q3: What is the most reliable risk prediction model to predict mortality in older and/or frail patients with advanced CKD (eGFR < 45 mL/min/1.73m2)666753098803.1 We suggest using the Bansal score to predict individual five year risk of death before ESKD in older people with CKD stage 3 to 5 (2C)3.2 We suggest that in patients at low risk on the Bansal score, a formal assessment of frailty be carried out as stated in 4.a. Frail patients should be managed as high risk (2C)3.3 We suggest the REIN score be used to predict the short term/6 month risk for mortality in older patients with CKD stage 5 (2B)003.1 We suggest using the Bansal score to predict individual five year risk of death before ESKD in older people with CKD stage 3 to 5 (2C)3.2 We suggest that in patients at low risk on the Bansal score, a formal assessment of frailty be carried out as stated in 4.a. Frail patients should be managed as high risk (2C)3.3 We suggest the REIN score be used to predict the short term/6 month risk for mortality in older patients with CKD stage 5 (2B)RationaleCounselling older people with advanced CKD on treatment options requires reliable estimates of an individual’s absolute probability of death within a given time frame, both with and without starting dialysis. Correctly identifying those people likely to die within the next few months, regardless of whether renal replacement therapy is started, may avoid them being subjected to the added burden of the dialysis pathway. On the other hand, identifying those likely to live longer, may inform shared decisions, balancing quality versus quantity of life. Few available risk prediction models have targeted older people with advanced CKD. Fewer still have been tested in populations outside those used to develop them. Hence it unclear whether existing models reliably help estimate risk of death in older people with advanced CKD. We found that the Bansal risk prediction model had the best credentials to be recommended as a tool for predicting the absolute probability of death within five years for older people with CKD stage 3 to 5 not on dialysisPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkJhbnNhbDwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [6]. The model includes nine readily available demographic, clinical and biochemical predictors: age, sex, ethnicity, eGFR, urinary albumin-to-creatinine ratio, diabetes, smoking, history of heart failure, and stroke. Model discrimination was moderate in both development and validation cohorts (c-statistic 0.72 and 0.69, respectively). External validation is lacking in cohorts including a substantial proportion of frail older patients. Since frailty is an independent risk factor for mortality ADDIN REFMGR.CITE <Refman><Cite><Author>Rockwood</Author><Year>2005</Year><RecNum>49</RecNum><IDText>A global clinical measure of fitness and frailty in elderly people</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>49</Ref_ID><Title_Primary>A global clinical measure of fitness and frailty in elderly people</Title_Primary><Authors_Primary>Rockwood,K.</Authors_Primary><Authors_Primary>Song,X.</Authors_Primary><Authors_Primary>MacKnight,C.</Authors_Primary><Authors_Primary>Bergman,H.</Authors_Primary><Authors_Primary>Hogan,D.B.</Authors_Primary><Authors_Primary>McDowell,I.</Authors_Primary><Authors_Primary>Mitnitski,A.</Authors_Primary><Date_Primary>2005/8/30</Date_Primary><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Female</Keywords><Keywords>Frail Elderly</Keywords><Keywords>Geriatric Assessment</Keywords><Keywords>Health Status</Keywords><Keywords>Humans</Keywords><Keywords>Institutionalization</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>mortality</Keywords><Keywords>Physical Fitness</Keywords><Keywords>Predictive Value of Tests</Keywords><Keywords>Prognosis</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Risk</Keywords><Reprint>Not in File</Reprint><Start_Page>489</Start_Page><End_Page>495</End_Page><Periodical>CMAJ.</Periodical><Volume>173</Volume><Issue>5</Issue><User_Def_5>PMC1188185</User_Def_5><Misc_3>173/5/489 [pii];10.1503/cmaj.050051 [doi]</Misc_3><Address>Division of Geriatric Medicine, Dalhousie University, Halifax, NS</Address><Web_URL>PM:16129869</Web_URL><ZZ_JournalStdAbbrev><f name="System">CMAJ.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[15], we hesitate to recommend the score as the sole means of predicting mortality in this population. A high Bansal score will deliver a reliable prediction irrespective of the presence of frailty, but in those with a low score, a validated frailty score is likely to contribute useful additional information on mortality. We found one validated risk prediction model developed from the REIN registry, estimating risk of death at three months following dialysis initiation in older people with ESKD (the REIN score) ADDIN REFMGR.CITE <Refman><Cite><Author>Couchoud</Author><Year>2015</Year><RecNum>50</RecNum><IDText>Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>50</Ref_ID><Title_Primary>Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease</Title_Primary><Authors_Primary>Couchoud,C.G.</Authors_Primary><Authors_Primary>Beuscart,J.B.</Authors_Primary><Authors_Primary>Aldigier,J.C.</Authors_Primary><Authors_Primary>Brunet,P.J.</Authors_Primary><Authors_Primary>Moranne,O.P.</Authors_Primary><Date_Primary>2015/11</Date_Primary><Keywords>Aged</Keywords><Keywords>epidemiology</Keywords><Keywords>mortality</Keywords><Keywords>Prognosis</Keywords><Keywords>Renal Replacement Therapy</Keywords><Keywords>Risk</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>1178</Start_Page><End_Page>1186</End_Page><Periodical>Kidney Int.</Periodical><Volume>88</Volume><Issue>5</Issue><Misc_3>S0085-2538(15)61002-X [pii];10.1038/ki.2015.245 [doi]</Misc_3><Address>REIN Registry, Agence de la biomedecine, Saint-Denis la Plaine, France
Department of Biostatistics, EA2694, Lille School of Medicine, Lille2 University, Lille, France
Geriatric Department, University Hospital, Lille, France
Nephrology Unit, Dupuytren University Hospital, Limoges, France
Nephrology Unit, APHM University Hospital, Marseille, France
Nephrology Unit, Caremeau University Hospital, Nimes, France
Biostatistics, Epidemiology and Public Health, Institut Universitaire de Recherche Clinique, University of Montpellier, Montpellier, France</Address><Web_URL>PM:26331408</Web_URL><ZZ_JournalStdAbbrev><f name="System">Kidney Int.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[7]. The model included nine demographic, clinical and biochemical predictors: age, sex, history of congestive heart failure, peripheral vascular disease, dysrhythmia, cancer, severe behavioural disorder, mobility and baseline serum albumin concentration. Model discrimination was moderate (c-statistic in the internal validation cohort was 0.75). A second risk prediction model estimating risk of death at six months following dialysis initiation in older people PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNvdWNob3VkPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48
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ADDIN EN.CITE.DATA [16], developed and internally validated in smaller cohorts from the same registry, had slightly inferior model discrimination (c-statistic 0.7). `Q4 (a). What is the best alternative method to assess functional decline in older and/ or frail patients with advanced CKDleft3155954a.1 We recommend a simple score be used on a regular basis to assess functional status in older patients with CKD stage 3b-5d with the intention to identify those who would benefit from more in depth geriatric assessment and rehabilitation. (1C)4a.2 We recommend that most simple scores, including self report scales and field tests (sit to stand, gait speed or 6 minute walk test) have comparable and sufficient discriminating power to identify patients with decreased functional status (1C)004a.1 We recommend a simple score be used on a regular basis to assess functional status in older patients with CKD stage 3b-5d with the intention to identify those who would benefit from more in depth geriatric assessment and rehabilitation. (1C)4a.2 We recommend that most simple scores, including self report scales and field tests (sit to stand, gait speed or 6 minute walk test) have comparable and sufficient discriminating power to identify patients with decreased functional status (1C)Advice for clinical practice On a regular basis implies 6-8 weekly for dialysis patients and at least at every clinic visit for patients with CKD stage 3b – 5 who are not yet on dialysisFrailty scores are interlinked with functional status and can provide additional information during assessment and shared decision making on management options.RationaleChronic Kidney Disease (CKD) is an independent risk factor for functional impairment and frailty and functional decline is associated with adverse outcomes including excess mortality and hospitalisation ADDIN REFMGR.CITE <Refman><Cite><Author>Painter</Author><Year>2013</Year><RecNum>52</RecNum><IDText>The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>52</Ref_ID><Title_Primary>The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease</Title_Primary><Authors_Primary>Painter,P.</Authors_Primary><Authors_Primary>Roshanravan,B.</Authors_Primary><Date_Primary>2013/11</Date_Primary><Keywords>Activities of Daily Living</Keywords><Keywords>Adult</Keywords><Keywords>Aging</Keywords><Keywords>Evidence-Based Medicine</Keywords><Keywords>Humans</Keywords><Keywords>Kidney</Keywords><Keywords>Kidney Transplantation</Keywords><Keywords>mortality</Keywords><Keywords>Motor Activity</Keywords><Keywords>Physical Fitness</Keywords><Keywords>physiology</Keywords><Keywords>physiopathology</Keywords><Keywords>Prevalence</Keywords><Keywords>Renal Insufficiency,Chronic</Keywords><Keywords>therapy</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>615</Start_Page><End_Page>623</End_Page><Periodical>Curr.Opin.Nephrol.Hypertens.</Periodical><Volume>22</Volume><Issue>6</Issue><Misc_3>10.1097/MNH.0b013e328365b43a [doi]</Misc_3><Address>aDepartment of Physical Therapy, University of Utah, Salt Lake City, Utah bKidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA</Address><Web_URL>PM:24100215</Web_URL><ZZ_JournalStdAbbrev><f name="System">Curr.Opin.Nephrol.Hypertens.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[17]. There is also evidence that interventions may reduce functional decline ADDIN REFMGR.CITE <Refman><Cite><Author>Heiwe</Author><Year>2014</Year><RecNum>53</RecNum><IDText>Exercise training in adults with CKD: a systematic review and meta-analysis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>53</Ref_ID><Title_Primary>Exercise training in adults with CKD: a systematic review and meta-analysis</Title_Primary><Authors_Primary>Heiwe,S.</Authors_Primary><Authors_Primary>Jacobson,S.H.</Authors_Primary><Date_Primary>2014/9</Date_Primary><Keywords>Adult</Keywords><Keywords>Exercise Therapy</Keywords><Keywords>Humans</Keywords><Keywords>Kidney</Keywords><Keywords>rehabilitation</Keywords><Keywords>Renal Insufficiency,Chronic</Keywords><Keywords>Risk</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>383</Start_Page><End_Page>393</End_Page><Periodical>Am.J.Kidney Dis.</Periodical><Volume>64</Volume><Issue>3</Issue><Misc_3>S0272-6386(14)00735-5 [pii];10.1053/j.ajkd.2014.03.020 [doi]</Misc_3><Address>Department of Clinical Science, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Division of Physical Therapy, Karolinska University Hospital, Stockholm, Sweden. Electronic address: susanne.heiwe@ki.se
Division of Nephrology, Danderyd University Hospital, Stockholm, Sweden; Division of Nephrology, Danderyd University Hospital, Stockholm, Sweden</Address><Web_URL>PM:24913219</Web_URL><ZZ_JournalStdAbbrev><f name="System">Am.J.Kidney Dis.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[18]. Several tools have been developed to assess the various domains of physical function in patients with CKD ADDIN REFMGR.CITE <Refman><Cite><Author>Painter</Author><Year>2013</Year><RecNum>54</RecNum><IDText>Assessing physical function and physical activity in patients with CKD</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>54</Ref_ID><Title_Primary>Assessing physical function and physical activity in patients with CKD</Title_Primary><Authors_Primary>Painter,P.</Authors_Primary><Authors_Primary>Marcus,R.L.</Authors_Primary><Date_Primary>2013/5</Date_Primary><Keywords>Actigraphy</Keywords><Keywords>Activities of Daily Living</Keywords><Keywords>Aging</Keywords><Keywords>Cost of Illness</Keywords><Keywords>diagnosis</Keywords><Keywords>Exercise Test</Keywords><Keywords>Exercise Tolerance</Keywords><Keywords>Humans</Keywords><Keywords>Motor Activity</Keywords><Keywords>Physical Examination</Keywords><Keywords>Physical Fitness</Keywords><Keywords>physiopathology</Keywords><Keywords>Predictive Value of Tests</Keywords><Keywords>Prognosis</Keywords><Keywords>Renal Insufficiency,Chronic</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>861</Start_Page><End_Page>872</End_Page><Periodical>Clin.J.Am.Soc.Nephrol.</Periodical><Volume>8</Volume><Issue>5</Issue><Misc_3>CJN.06590712 [pii];10.2215/CJN.06590712 [doi]</Misc_3><Address>Department of Physical Therapy University of Utah, Salt Lake City, Utah 84108, USA. trish.painter@hsc.utah.edu</Address><Web_URL>PM:23220421</Web_URL><ZZ_JournalStdAbbrev><f name="System">Clin.J.Am.Soc.Nephrol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[19]. These have been categorised into laboratory based measures of physiologic impairment, measures of mobility and performance capacity which are either self-reported or obtained from field tests, and measures of physical activity. There is however no consensus on the most appropriate tool for assessing physical function in older patients with advanced CKD Evidence suggests that functional decline in older patients with CKD can feasibly be assessed using a combination of self- reporting and field tests. Such screening can help identify patients at risk who should be further evaluated by an experienced physician and/or multi-disciplinary team. The evidence suggests that all simple scores and tests perform reasonably well. None stands out as being specifically relevant for this particular cohort. Self-report measures of physical performance are simple, easy to use, reliable with good internal consistency, and predictive of adverse outcomes including mortality and hospitalisation. It is unclear though, how sensitive they are to changes over time. Field tests of mobility and physical performance such as Sit to Stand, gait speed and the 6 minute walk have been validated in cohorts that include older CKD patients. They have been shown to have good test – retest and interrater reliability, whilst also being predictive of adverse outcomes. They have also been shown to respond to interventions aimed at improving functional status. Physiologic measures such as vO2 max are difficult to incorporate into practice and have a limited role in this setting. Q4b: Are interventions aimed at increasing functional status in older patients with renal failure (eGFR <45 mL/min/1.73m? or on dialysis) of benefit?190503124204b.1 We recommend that exercise has a positive impact on the functional status of older patients with CKD stage 3b or higher (1C) 4b.2 We suggest that exercise training be offered in a structured and individualized manner to avoid adverse events (2C) 004b.1 We recommend that exercise has a positive impact on the functional status of older patients with CKD stage 3b or higher (1C) 4b.2 We suggest that exercise training be offered in a structured and individualized manner to avoid adverse events (2C) Advice for clinical practice"Individualized" means that the prescription is tailored to the needs and capacities of the patient. This can ideally be achieved by involving a clinical physiotherapist to prescribe a mix of strength and endurance exercises on a regular basis within the physical limitations of the patient. Combined strength and endurance exercise should be provided on a regular basisIn patients on haemodialysis exercise training can be administered during the first two hours of the dialysis session. Regular follow-up is important in order to optimize adherence and adjust the exercise intensity.The evidence on positive outcomes of exercise tends to originate from programmes benefitting from intensive involvement of motivated physiotherapy teams There is little evidence that augmented dialysis improves functional status in the absence of multidisciplinary physiotherapy and nutritional interventionsRationaleDue to the ageing of the CKD population and the associated increase of frailty in this group, it is important to formulate guidelines on how to maintain or improve functional status in an older CKD population. This question explored evidence regarding interventions that effectively improve functional status in frail older people with advanced CKD stages 3B or higher (eGFR<45ml/min/1.73m2) or on maintenance dialysis.The available evidence is consistent in supporting a positive impact on the physical, functional and psychological well being of CKD patients who perform exercise. Older patients with CKD were able to respond with increased physical function to exercise training. None of the studies reported any adverse events or negative effects, which supports the safety and feasibility of exercise training in this setting. However all patients had been carefully screened by a physician before participation. Furthermore studies were generally small, and there was a high risk for selection bias. In addition it is noteworthy that exercise programmes were closely monitored by a team including a physiotherapist, and that most adapted the intensity of the exercise to the individual capacity of the patient. This may account for some of the benefits described and the lack of adverse events. The guideline development group therefore suggests that exercise programmes are supervised by a physiotherapist as a part of structured multi-disciplinary programmeQ5a: Which is the best alternative to evaluate nutritional status in older patients with advanced CKD 3b or higher (eGFR<45ml/min/1.73m2) or on dialysisleft3092455a.1 We recommend the Subjective Global Assessment (SGA) as the gold standard to assess nutritional status of older patients with CKD stage 3b or higher (eGFR <45ml/min) (1C).5a.2 We suggest that in older patients on haemodialysis, a score including serum albumin, body mass index, serum creatinine/body surface area and normalised Protein Nitrogen Appearance (nPNA) may be used to assess nutritional status (2D)005a.1 We recommend the Subjective Global Assessment (SGA) as the gold standard to assess nutritional status of older patients with CKD stage 3b or higher (eGFR <45ml/min) (1C).5a.2 We suggest that in older patients on haemodialysis, a score including serum albumin, body mass index, serum creatinine/body surface area and normalised Protein Nitrogen Appearance (nPNA) may be used to assess nutritional status (2D)RationaleImportant nutritional deficiencies occur in patients with advanced CKD stage 3b or higher (eGFR<45ml/min) as a result of metabolic defects, chronic inflammation, loss of appetite, repeated surgical interventions or infectious episodes PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkpvaGFuc3NvbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+
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ADDIN EN.CITE.DATA . Older patients are at high risk of wasting because of reduced appetite and a high prevalence of multi-morbidity, social isolation and depression. In an aging dialysis population it is important to identify reliable, easy to use tools which allow routine assessment of nutritional status, so that patients at risk can be considered for further assessment and management. We found a high degree of consensus among studies that SGA provides an acceptable estimate of nutritional status, is related to relevant patient outcomes (morbidity and mortality) and that it is sufficiently sensitive to reliably capture changes in nutritional status. SGA is reasonably easy to perform, relatively brief and can thus be used on a routine basis. The guideline development group suggests the use of SGA as a gold standard for routine assessment of nutritional status. For older patients on dialysis, a score including serum albumin, body mass index, serum creatinine normalised to body surface area and nPNA may be used to assess nutritional status PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1vcmVhdS1HYXVkcnk8L0F1dGhvcj48WWVhcj4yMDE0PC9Z
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ADDIN EN.CITE.DATA [22]. It has been shown to have an acceptable predictive value for mortality and improvements in the score are associated with improved outcomes. External validation though is lacking. left6673855b.1 We suggest a trial of structured dietary advice and support with the aim of improving nutritional status (2C)005b.1 We suggest a trial of structured dietary advice and support with the aim of improving nutritional status (2C)Q5b: Which interventions are effective in improving nutritional status in older/frail patients with advanced CKD (eGFR < 45ml/min/1.73m2) or on dialysis?Advice for clinical practice:Preserving nutritional status should prevail over any other dietary restriction There is insufficient evidence to prefer intravenous (intradialytic) nutritional support over oral nutritional supportCorrecting metabolic acidosis by oral supplementation is safe and cheap. Rationale Malnutrition and protein energy wasting are prevalent in the older patients with advanced CKD (eGFR<45ml/min/1.73m2) and are associated with excess mortality PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkpvaGFuc3NvbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+
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ADDIN EN.CITE.DATA [20-22]. Improvements in nutritional status have been reported to improve clinical outcomes, but though a variety of nutritional, pharmacological and dialytic interventions have been suggested, hard evidence from well-controlled and sufficiently powered randomized studies is lacking. Patients with advanced CKD (eGFR<45ml/min/1.73m?) are often placed on restrictive diets. For older patients these restrictions often come on top of many other factors which potentially compromise nutritional intake, such as social deprivation, functional and cognitive impairment, multi-morbidity, dental problems, depression, and polypharmacy. For all these reasons, there remains uncertainty about optimal nutritional care for the older patient with advanced CKD, and a need for evidence based guidelines on the prevention and management of malnutrition in this setting. Most studies of oral nutritional supplements reported statistically significant improvements of nutritional parameters including serum albumin and SGA. Similar improvements were demonstrated with intradialyic parenteral nutrition, though in one RCT this therapy conferred no additional benefit over oral supplements PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhbm88L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxSZWNO
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ADDIN REFMGR.CITE PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkNhbm88L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA [23]. Correcting metabolic acidosis by oral sodium bicarbonate improved albumin and/or SGA and appeared safe PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlZlcm92ZTwvQXV0aG9yPjxZZWFyPjIwMDI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [26]. In general the quality of evidence was poor, consisting largely of single centre observational studies with low patient numbers and short follow up. There were few RCTs. There was no consensus on the definition of nutritional status, inclusion criteria, or on which surrogate outcomes are relevant in this population. No studies addressed the impact of nutritional intervention on mortality. All these factors make it difficult to assess the effectiveness of these interventions.Q6: What is the benefit of dialysis in frail and older patients?6.1 We recommend use of validated tools as explained in Q2 and Q3 to project likely outcomes and help decide the appropriateness of discussing options for renal replacement therapy (see flow chart 1). 6.2 We recommend that the option for conservative management be discussed during the shared decision making process on different management options for end stage renal disease (1D) 6.3 We recommend the REIN score can be useful to stratify short term/6 month mortality risk of patients intending to start renal replacement therapy (1C)Advice for Clinical Practice*Evidence on this topic derives from observational studies only* For frail, older patients with stage 5 CKD the survival benefits of dialysis over conservative management are uncertain * Probability, life expectancy, Quality of Life impact and experience of being on dialysis, are difficult concepts. Use of patient friendly tools to help visualize these concepts and may be helpful in enhancing patient understanding of the implications of different treatment options.*Multidisciplinary assessment of older patients with stage 5 CKD should include cognitive function, frailty, comorbidities, and nutritional, functional and psychosocial factorsRationaleWhy this question?The number of older patients receiving dialysis treatment has increased dramatically over recent years. Mortality is particularly high in this group and a substantial part of this is due to dialysis withdrawal PFJlZm1hbj48Q2l0ZT48QXV0aG9yPnZhbjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA [28;29]. Undertaking dialysis also impacts on quality of life. Providing some symptom relief comes at the cost of significant burdens for the patient, their families and carers. Hence difficult decisions have to be made about whether any potential survival benefits for a particular individual are acceptable to that individual taking into consideration the rigours of the treatment. Studies on decisions about the appropriateness of dialysis for patients with frailty, advanced age and high co-morbidity have demonstrated wide discrepancies in clinician, patient and carer choices. Hence this question was posed as part of the guideline to try to support clinicians in helping patients faced with this common, complex and challenging decision.The guideline development group considers that there are sufficient data to indicate that CM may be a viable treatment option for older and/or co-morbid and/or poor functional status which may not adversely affect survival or QoL. Choosing CM over dialysis may avoid hospital admissions and improve access to palliative care. However the evidence derives from observational studies only. These were of variable size and quality. Populations were defined by different criteria, measuring different outcomes over different time periods in different eras. There was no consistent definition of CM. Most studies defined patients only according to age. Frailty was formally assessed in only one study PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlJvZHJpZ3VlejwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+
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ADDIN EN.CITE.DATA [30]. Decisions about whether to opt for dialysis or not should take place some considerable time before dialysis may be necessary. There are validated tools which can guide shared decision making. The 4-variable Kidney Failure Risk Equation PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlRhbmdyaTwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [6] (see Questions 2 and 3) inform assessment of the competing risks of progression of kidney failure and death in those with advanced CKD (Flowchart 1). The REIN score ADDIN REFMGR.CITE <Refman><Cite><Author>Couchoud</Author><Year>2015</Year><RecNum>50</RecNum><IDText>Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>50</Ref_ID><Title_Primary>Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease</Title_Primary><Authors_Primary>Couchoud,C.G.</Authors_Primary><Authors_Primary>Beuscart,J.B.</Authors_Primary><Authors_Primary>Aldigier,J.C.</Authors_Primary><Authors_Primary>Brunet,P.J.</Authors_Primary><Authors_Primary>Moranne,O.P.</Authors_Primary><Date_Primary>2015/11</Date_Primary><Keywords>Aged</Keywords><Keywords>epidemiology</Keywords><Keywords>mortality</Keywords><Keywords>Prognosis</Keywords><Keywords>Renal Replacement Therapy</Keywords><Keywords>Risk</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>1178</Start_Page><End_Page>1186</End_Page><Periodical>Kidney Int.</Periodical><Volume>88</Volume><Issue>5</Issue><Misc_3>S0085-2538(15)61002-X [pii];10.1038/ki.2015.245 [doi]</Misc_3><Address>REIN Registry, Agence de la biomedecine, Saint-Denis la Plaine, France
Department of Biostatistics, EA2694, Lille School of Medicine, Lille2 University, Lille, France
Geriatric Department, University Hospital, Lille, France
Nephrology Unit, Dupuytren University Hospital, Limoges, France
Nephrology Unit, APHM University Hospital, Marseille, France
Nephrology Unit, Caremeau University Hospital, Nimes, France
Biostatistics, Epidemiology and Public Health, Institut Universitaire de Recherche Clinique, University of Montpellier, Montpellier, France</Address><Web_URL>PM:26331408</Web_URL><ZZ_JournalStdAbbrev><f name="System">Kidney Int.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[7](see Question 3) estimates short-term mortality risk should dialysis be embarked on. Tools to assist shared decision making are also available. Visual tools may help patients understand risks ADDIN REFMGR.CITE <Refman><Cite><Author>Peeters</Author><Year>2016</Year><RecNum>67</RecNum><IDText>External Validation of a risk stratification model to assist shared decision making for patients starting renal replacement therapy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>67</Ref_ID><Title_Primary>External Validation of a risk stratification model to assist shared decision making for patients starting renal replacement therapy</Title_Primary><Authors_Primary>Peeters,P.</Authors_Primary><Authors_Primary>van,Biesen W.</Authors_Primary><Authors_Primary>Veys,N.</Authors_Primary><Authors_Primary>Lemahieu,W.</Authors_Primary><Authors_Primary>De,Moor B.</Authors_Primary><Authors_Primary>De,Meester J.</Authors_Primary><Date_Primary>2016</Date_Primary><Keywords>analysis</Keywords><Keywords>Comorbidity</Keywords><Keywords>Decision Making</Keywords><Keywords>Dialysis</Keywords><Keywords>methods</Keywords><Keywords>mortality</Keywords><Keywords>Prognosis</Keywords><Keywords>Quality of Life</Keywords><Keywords>Registries</Keywords><Keywords>Renal Replacement Therapy</Keywords><Keywords>Risk</Keywords><Keywords>therapy</Keywords><Reprint>Not in File</Reprint><Start_Page>41</Start_Page><Periodical>BMC.Nephrol.</Periodical><Volume>17</Volume><User_Def_5>PMC4823864</User_Def_5><Misc_3>10.1186/s12882-016-0253-3 [doi];10.1186/s12882-016-0253-3 [pii]</Misc_3><Address>Renal Division, Department Of Internal Medicine, Ghent University Hospital, Ghent, Belgium
Renal Division, Department Of Internal Medicine, Ghent University Hospital, Ghent, Belgium. wim.vanbiesen@ugent.be
Renal Division, Department Of Internal Medicine, Ghent University Hospital, Ghent, Belgium
Renal Division, Imelda Ziekenhuis, Bonheiden, Belgium
Renal Division, Jessa Hospital, Hasselt, Belgium
Renal Division, AZ Nikolaas, St-Niklaas, Belgium</Address><Web_URL>PM:27055653</Web_URL><ZZ_JournalStdAbbrev><f name="System">BMC.Nephrol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[31]. ADDIN REFMGR.REFLIST Reference List1 ERBP: Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR<45ml/min). Nephrology, Dialysis, Transplantation 2016.2 van der Veer SN, van BW, Bernaert P, Bolignano D, Brown EA, Covic A, Farrington K, Jager KJ, Kooman J, Macias-Nunez JF, Mooney A, van Munster BC, Topinkova E, Van Den Noortgate NJ, Wirnsberger G, Michel JP, Nistor I: Priority topics for European multidisciplinary guidelines on the management of chronic kidney disease in older adults. Int Urol Nephrol 2016;48:859-869.3 Nagler EV, Webster AC, Bolignano D, Haller MC, Nistor I, van der Veer SN, Fouque D, van BW: European Renal Best Practice (ERBP) Guideline development methodology: towards the best possible guidelines. Nephrol Dial Transplant 2014;29:731-738.4 Tangri N, Grams ME, Levey AS, Coresh J, Appel LJ, Astor BC, Chodick G, Collins AJ, Djurdjev O, Elley CR, Evans M, Garg AX, Hallan SI, Inker LA, Ito S, Jee SH, Kovesdy CP, Kronenberg F, Heerspink HJ, Marks A, Nadkarni GN, Navaneethan SD, Nelson RG, Titze S, Sarnak MJ, Stengel B, Woodward M, Iseki K: Multinational Assessment of Accuracy of Equations for Predicting Risk of Kidney Failure: A Meta-analysis. JAMA 2016;315:164-174.5 Tangri N, Stevens LA, Griffith J, Tighiouart H, Djurdjev O, Naimark D, Levin A, Levey AS: A predictive model for progression of chronic kidney disease to kidney failure. JAMA 2011;305:1553-1559.6 Bansal N, Katz R, De Boer IH, Peralta CA, Fried LF, Siscovick DS, Rifkin DE, Hirsch C, Cummings SR, Harris TB, Kritchevsky SB, Sarnak MJ, Shlipak MG, Ix JH: Development and validation of a model to predict 5-year risk of death without ESRD among older adults with CKD. Clin J Am Soc Nephrol 2015;10:363-371.7 Couchoud CG, Beuscart JB, Aldigier JC, Brunet PJ, Moranne OP: Development of a risk stratification algorithm to improve patient-centered care and decision making for incident elderly patients with end-stage renal disease. Kidney Int 2015;88:1178-1186.8 Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, Van LF, Levey AS: Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038-2047.9 Hallan SI, Dahl K, Oien CM, Grootendorst DC, Aasberg A, Holmen J, Dekker FW: Screening strategies for chronic kidney disease in the general population: follow-up of cross sectional health survey. BMJ 2006;333:1047.10 Johnson ES, Thorp ML, Platt RW, Smith DH: Predicting the risk of dialysis and transplant among patients with CKD: a retrospective cohort study. Am J Kidney Dis 2008;52:653-660.11 Johnson ES, Thorp ML, Yang X, Charansonney OL, Smith DH: Predicting renal replacement therapy and mortality in CKD. Am J Kidney Dis 2007;50:559-565.12 Li L, Astor BC, Lewis J, Hu B, Appel LJ, Lipkowitz MS, Toto RD, Wang X, Wright JT, Jr., Greene TH: Longitudinal progression trajectory of GFR among patients with CKD. Am J Kidney Dis 2012;59:504-512.13 Coca SG, Singanamala S, Parikh CR: Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int 2012;81:442-448.14 O'Hare AM, Choi AI, Bertenthal D, Bacchetti P, Garg AX, Kaufman JS, Walter LC, Mehta KM, Steinman MA, Allon M, McClellan WM, Landefeld CS: Age affects outcomes in chronic kidney disease. J Am Soc Nephrol 2007;18:2758-2765.15 Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A: A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489-495.16 Couchoud C, Labeeuw M, Moranne O, Allot V, Esnault V, Frimat L, Stengel B: A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease. Nephrol Dial Transplant 2009;24:1553-1561.17 Painter P, Roshanravan B: The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease. Curr Opin Nephrol Hypertens 2013;22:615-623.18 Heiwe S, Jacobson SH: Exercise training in adults with CKD: a systematic review and meta-analysis. Am J Kidney Dis 2014;64:383-393.19 Painter P, Marcus RL: Assessing physical function and physical activity in patients with CKD. Clin J Am Soc Nephrol 2013;8:861-872.20 Johansson L, Fouque D, Bellizzi V, Chauveau P, Kolko A, Molina P, Sezer S, Ter Wee PM, Teta D, Carrero JJ: As we grow old: nutritional considerations for older patients on dialysis. Nephrol Dial Transplant 2016.21 Ikizler TA, Cano NJ, Franch H, Fouque D, Himmelfarb J, Kalantar-Zadeh K, Kuhlmann MK, Stenvinkel P, TerWee P, Teta D, Wang AY, Wanner C: Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int 2013;84:1096-1107.22 Moreau-Gaudry X, Jean G, Genet L, Lataillade D, Legrand E, Kuentz F, Fouque D: A simple protein-energy wasting score predicts survival in maintenance hemodialysis patients. J Ren Nutr 2014;24:395-400.23 Cano NJ, Fouque D, Roth H, Aparicio M, Azar R, Canaud B, Chauveau P, Combe C, Laville M, Leverve XM: Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol 2007;18:2583-2591.24 Verove C, Maisonneuve N, El AA, Boldron A, Azar R: Effect of the correction of metabolic acidosis on nutritional status in elderly patients with chronic renal failure. J Ren Nutr 2002;12:224-228.25 Szeto CC, Wong TY, Chow KM, Leung CB, Li PK: Oral sodium bicarbonate for the treatment of metabolic acidosis in peritoneal dialysis patients: a randomized placebo-control trial. J Am Soc Nephrol 2003;14:2119-2126.26 Slinin Y, Guo H, Gilbertson DT, Mau LW, Ensrud K, Collins AJ, Ishani A: Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis. Am J Kidney Dis 2011;58:583-590.27 van BW, van de Luijtgaarden MW, Brown EA, Michel JP, van Munster BC, Jager KJ, van der Veer SN: Nephrologists' perceptions regarding dialysis withdrawal and palliative care in Europe: lessons from a European Renal Best Practice survey. Nephrol Dial Transplant 2015;30:1951-1958.28 O'Connor NR, Kumar P: Conservative management of end-stage renal disease without dialysis: a systematic review. J Palliat Med 2012;15:228-235.29 Foote C, Kotwal S, Gallagher M, Cass A, Brown M, Jardine M: Survival outcomes of supportive care versus dialysis therapies for elderly patients with end-stage kidney disease: A systematic review and meta-analysis. Nephrology (Carlton ) 2016;21:241-253.30 Rodriguez V, I, Ortega O, Hinostroza J, Cobo G, Gallar P, Mon C, Herrero JC, Ortiz M, Di GC, Oliet A, Vigil A: Geriatric assessment for therapeutic decision-making regarding renal replacement in elderly patients with advanced chronic kidney disease. Nephron Clin Pract 2014;128:73-78.31 Peeters P, van BW, Veys N, Lemahieu W, De MB, De MJ: External Validation of a risk stratification model to assist shared decision making for patients starting renal replacement therapy. BMC Nephrol 2016;17:41.Flowchart 1. Proposed management pathway for older patients with advanced CKD. KRFE score is the 4-variable Kidney Failure Risk Equation (see Question 2). For Bansal and Rein Score see Question 3. This document was produced with the financial and logistical support of the European Renal Association/European Dialysis and Transplant Association ................
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