Jessica W. Weiss

Systolic Blood Pressure and Mortality Among Older, Community-Dwelling Adults With CKD

BACKGROUND Chronic kidney disease (CKD) is an increasingly common condition, especially in older adults. CKD manifests differently in older versus younger patients, with a risk of death that far outweighs the risk of CKD progressing to the point that dialysis is required. Current CKD guidelines recommend a blood pressure target <130/80 mm Hg for all patients with CKD; however, it is unknown how lower versus higher baseline blood pressures may affect older adults with CKD. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Older patients (aged ≥ 75 years) with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m(2)) in a community-based health maintenance organization. PREDICTOR Baseline systolic blood pressure (SBP) < 130, 130-160 (reference group), and > 160 mm Hg. OUTCOMES Participants were followed up for 5 years to examine rates of mortality (primary outcome) and cardiovascular disease hospitalizations (secondary outcome). RESULTS At baseline, 3,099 participants (38.5%) had SBP < 130 mm Hg, 3,772 (46.9%) had SBP of 131-160 mm Hg, and 1,171 (14.6%) had SBP >160 mm Hg. A total of 3,734 (46.4%) died and 2,881 (35.8%) were hospitalized. Adjusted HRs for mortality in the groups with SBP < 130 and > 160 mm Hg were 1.22 (95% CI, 1.11-1.34) and 1.06 (95% CI, 0.93-1.22), respectively. Adjusted HRs for cardiovascular hospitalization in these groups were 1.10 (95% CI, 0.99-1.23) and 1.26 (95% CI, 1.09-1.45), respectively. LIMITATIONS Although causality should not be inferred from this retrospective analysis, results from this study can generate hypotheses for future randomized controlled trials to investigate the relationship between blood pressure and outcomes in older patients with CKD. CONCLUSIONS Our study suggests that lower baseline SBP (≤ 130 mm Hg) may predict poorer outcomes in terms of both mortality and cardiovascular hospitalizations in older adults with CKD. Conversely, higher baseline SBP (> 160 mm Hg) may predict increased risk of cardiovascular hospitalizations, but does not predict mortality. Clinical trials are required to test this hypothesis.

Systolic BP and Mortality in Older Adults with CKD

BACKGROUND AND OBJECTIVES Optimal BP targets for older adults with CKD are unclear. This study sought to determine whether a nonlinear relationship between BP and mortality-as described for the broader CKD population and for older adults in the general population-is present for older adults with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A cohort of 21,015 adults age 65-105 years with a moderate or severe reduction in eGFR (<60 ml/min per 1.73 m(2)) were identified within the Kaiser Permanente Northwest Health Maintenance Organization population. The relationship between baseline systolic BP (SBP; ≤120, 121-130, 131-140, 141-150, >150 mmHg; referent, 131-140 mmHg) and all-cause mortality across age groups (65-70, 71-80, and >80 years) was examined; patients were followed for up to 11 years after cohort entry. RESULTS The median times at risk were 3.15 years, 3.53 years, and 2.76 years for adults age 65-70, 71-80, and >80 years, respectively. Mortality during follow-up was 19.6% for those age 65-70 years, 33.4% for those age 71-80 years, and 55.7% for those age >80 years. The relationship between SBP and mortality varied as a function of age. The risk of death was highest for patients with the lowest SBP in all age groups. Only among adults age 65-70 years was an SBP>140 mmHg associated with a higher risk of death compared with the referent category. Patterns of age modification of the relationship between SBP and mortality were consistent in all sensitivity analyses. CONCLUSIONS In a cohort of older adults, the relationship between SBP and mortality varied systematically with age. A relationship between higher SBP and mortality was present only for younger members of this cohort and not for those older than 70. These results raise the question of whether the relative benefits and harms of lowering BP to recommended targets for older adults with CKD may vary as a function of age.

Predicting Mortality in Older Adults with Kidney Disease: A Pragmatic Prediction Model

To develop mortality risk prediction models for older adults with chronic kidney disease (CKD) that include comorbidities and measures of health status and use not associated with particular comorbid conditions (nondisease‐specific measures).

Acute phosphate nephropathy: a cause of chronic kidney disease

Acute phosphate nephropathy occurs whenever a patient with renal dysfunction is exposed to high doses of phosphate. Bowel purgative agents are a common source of high doses of sodium phosphate and are widely used as bowel preparation agents prior to colonoscopy due to their efficacy and tolerability. Oral sodium phosphate (OSP) preparations used to prepare patients for colonoscopy may be a cause of acute and chronic kidney disease (CKD). CKD associated with OSP agents is the result of nephrocalcinosis, or calcium phosphorus crystal deposition in the renal parenchyma leading to interstitial disease. It is often irreversible and progressive in nature. The authors report a case of CKD which presented with non-specific symptoms weeks after use of an OSP agent as part of a bowel preparation regimen. Renal biopsy confirmed nephrocalcinosis.

Renin-angiotensin system blockade in older adults with chronic kidney disease: a review of the literature.

Purpose of reviewWe have reviewed the literature examining the benefits and harms of renin–angiotensin system (RAS) blockade in older adults, using studies which included patients with chronic kidney disease (CKD) as well as those which included a broader patient population. Recent findingsWe review the results of key trials which evaluate the impact of RAS blockade on renal outcomes, and those which address the impact of RAS blockade on more global outcomes (cardiovascular events and mortality). Many trials examining renal outcomes of RAS blockade excluded older patients or did not present age-stratified results, whereas trials which examined global outcomes often excluded patients with CKD. Most older patients with CKD have nonproteinuric nondiabetic CKD, thus differing from participants in trials which examined renal outcomes, which often included only patients with diabetes or proteinuria. Most studies did not address alternate outcomes which may carry greatest import for older patients, such as worsening comorbid illness or changes in functional status. SummaryThe role of RAS inhibition for older patients with CKD remains unclear. Information on age-specific effects of RAS blockade on a range of different outcomes among older patients with CKD would improve our ability to assess the benefits and harms of RAS inhibition in this population.

Managing complexity in older patients with CKD

The increasing number of adults surviving to older ages has led to increasing incidence and prevalence of those diseases common among older adults, including CKD ([1][1]). CKD in older persons rarely occurs in isolation and is frequently concomitant with those diseases that contribute to CKD

Should measuring haemoglobin among chronic kidney disease patients be a performance measure

Objective: We attempted to: (1) to assess whether or not adequate evidence exists to advocate the measurement of anaemia in chronic kidney disease as a performance measure; and (2) to determine what the appropriate benchmarks might be for health systems seeking to implement this performance measure.

The Continued Quest for Optimal BP Targets in Older Adults with Kidney Disease

Since the landmark Veteran’s Affairs Cooperative Trials of the late 1960s to 1970s, hypertension management has played a central role in efforts to decrease cardiovascular risk ([1][1],[2][2]). Given the prevalence of isolated systolic hypertension in older adults, later studies in older

PS3-34: Does Reporting of Estimated Glomerular Filtration Rates Affect Clinician Behavior?

Background/Aims The National Kidney Disease Education Project and other groups have recommended automated calculation and reporting of estimated glomerular filtration (eGFR) rates among all patients who have a serum creatinine measured. Few studies have assessed whether clinical practice patterns have changed in response to this new initiative. We conducted a time series analysis assessing the rate of nephrology referrals, visits and follow up laboratory testing before and after automated reporting was implemented. Methods We conducted a retrospective cohort study of patients who had incident eGFR levels <60 measured before and after implementation of eGFR reporting at Kaiser Permanente Northwest (KPNW). We compared rates of subsequent evidence of clinical recognition including nephrology referral, repeat serum creatinine and proteinuria testing before and after implementation of eGFR reporting. Logistic models were used to compare change in clinical recognition rates controlling for baseline trends, and determine if the change in rates is related to clinician characteristics. Results We found 21,612 patients who had an eGFR <60, had been members for 2 years, were 18 years or older, and did not have a diagnosis of CKD. The number of referrals increased after the eGFR by 1.3 referrals per month (P = .05). However, the trend in monthly referral slowed after eGFR by .59 per month in comparison to the baseline trend (P = .02). Differences in the change in likelihood of referral after eGFR were found for age (P =.01), amount of FTE (P = .04), and type of practice (P = .01). Slope changes in subsequent orders for other testing (i.e., proteinuria) were not significant. Conclusions Following implementation of eGFR reporting, the likelihood of referral to nephrologists increased though the number of nephrology clinic visits did not. Clinicians who were younger, family medicine, and worked full time were more likely to increase referrals after eGFR.