National Kidney Foundation (NKF): Spring Clinical Meetings

NATIONAL HARBOR, MD – The prognosis for older adult kidney transplant recipients has improved dramatically in recent years, and these individuals deserve to be referred for transplantation more often than they currently are, according to transplant surgeon, Dr. Dorry Segev.

Dr. Segev pointed to data from his own and other studies, showing that not only have survival rates among older adult kidney recipients improved, but the use of donor kidneys from older adults can in some cases be considered acceptable for younger recipients.

"What we knew about transplantation 20 years ago is completely different now. Immunosuppression agents are better, clinical protocols are better. ...Those aged 65 and older can have pretty good outcomes with transplantation," said Dr. Segev of the department of surgery at Johns Hopkins University, Baltimore.

Today, 2-year survival following kidney transplantation among those aged 65 and older is approximately 90%, based on data from 7,823 patients who were transplanted in 2009-2011, in contrast to about 80% among 1,153 who were transplanted in 1991-1993. And, older adults who do receive kidney transplants have almost double the survival benefit, compared with those who remain on the waiting list. "We’re transplanting more older adults, and they’re doing better," Dr. Segev said

Nevertheless, about 300,000 adults aged 65 years and older are currently on the waiting list for donor kidneys, and there is evidence that these individuals are referred for transplantation less often than younger individuals with chronic kidney disease. In another study from Dr. Segev’s group, national registry data on 6,988 Medicare recipients (aged 65 and older) of a first kidney transplant in 1999-2006 were compared with those of 128,850 older adults with end-stage renal disease in those same years who did not have absolute or relative contraindications to transplantation (J. Am. Geriatr. Soc. 2012;60:1-7).

Of the 11,756 who would be considered "excellent" candidates for transplantation (defined as greater than 87% predicted 3-year posttransplantation survival, corresponding to the top 20% of transplanted older adults), just 24% had access to transplantation and 13% actually received a kidney transplant. It was estimated that 11% of these candidates would have identified a suitable live donor had they been referred for kidney transplantation. "Those who should be transplanted are getting referred at an extremely low rate," Dr. Segev commented.

One way to counter the belief that donor kidneys are "wasted" on adults with lower remaining life expectancy is to consider kidney options that may not be appropriate for younger recipients, including "expanded criteria" donor kidneys, older living donors, and a special category designated by the Centers for Disease Control and Prevention as "infectious disease risk" donors.

"Expanded criteria" donors (ECDs) include those who are aged 60 years and older, or age 50-59 with two of the following three criteria: hypertension, stroke as the cause of death, or terminal creatinine greater than 1.5 mg/dL. There is a separate recipient waiting list for ECDs, of which "many are great kidneys," Dr. Segev said.

In a review of 142,907 first-time deceased-donor kidney registrants who were reported to UNOS (United Network for Organ Sharing) between 2003 and 2008, Dr. Segev and his associates found that just 67% of adults older than 65 years who were predicted to benefit from ECDs were listed for them, with huge variation (0% to 100%) by center (Am. J. Transplant. 2010;10:802-9).

Older living donors are another potential – but underutilized – source of donor kidneys for their peers. Among 219 healthy adults aged 70 and older who have donated kidneys at 80 U.S. transplantation centers, graft loss in the recipients was significantly higher than were matched 50- to 59-year-old, live-donor allografts, but were similar to matched, nonextended-criteria, 50- to 59-year-old, deceased-donor allografts. Mortality among the older living kidney donors was no higher than that among healthy matched controls, and in fact they lived longer (Clin. J. Am. Soc. Nephrol. 2011;6:2887-93).

"The study showed that donors do well and recipients do well, particularly older recipients. ... Many older adults have a social network of other older adults who would be willing to donate if they knew it was possible," Dr. Segev said.

Another source of alternative donor organs that might be appropriate for selected elderly patients are those from the Centers for Disease Control and Prevention’s "Infectious Risk Donors." These include men who have sex with men (MSM), injection drug users, hemophiliacs, prostitutes, those exposed to HIV, those who have had sex with anyone in the previous categories, and incarcerated individuals. Such donors account for nearly 10% of the donor pool, and their organs are discarded more often than other donor organs.

"It seems wasteful to discard these. There should be someone on the list who would benefit from them, even with higher infectious risk. The real diseases we worry about – HIV and HCV [hepatitis C virus] – take years for sequelae to develop," Dr. Segev said.

In two separate studies, the risk of infection from such an organ per 10,000 donors during the "window period" prior to positive test results for injection drug users was 4.9 for HIV and 32.4 for HCV. For MSM, those risks were 4.2 and 3.5, respectively, and for commercial sex workers, 2.7 and 12.3, respectively. The others incurred lower risks (Am. J. Transplant. 2011;1176-87; 11:1188-200).

New data from Dr. Segev’s group suggest that the risk of a poor outcome (defined as 33% or more of the year after the kidney transplantation that was spent hospitalized or dying) among older transplant recipients increases by an adjusted odds ratio of 1.42 per 10 years. Years on pretransplantation dialysis also was a significant predictor (1.11), whereas the receipt of a live donor organ was protective (0.59).

In all, the risks of kidney transplantation for older adults include the upfront risks of surgery, particularly among those with comorbidities; the risk of immunosuppression; and the ongoing need for medical follow-up. But the benefits can include longer survival and improved quality of life, Dr. Segev said.

Dr. Segev disclosed that he is a consultant, scientific advisor, and speaker for Sanofi.

NATIONAL HARBOR, MD – The prognosis for older adult kidney transplant recipients has improved dramatically in recent years, and these individuals deserve to be referred for transplantation more often than they currently are, according to transplant surgeon, Dr. Dorry Segev.

Dr. Segev pointed to data from his own and other studies, showing that not only have survival rates among older adult kidney recipients improved, but the use of donor kidneys from older adults can in some cases be considered acceptable for younger recipients.

"What we knew about transplantation 20 years ago is completely different now. Immunosuppression agents are better, clinical protocols are better. ...Those aged 65 and older can have pretty good outcomes with transplantation," said Dr. Segev of the department of surgery at Johns Hopkins University, Baltimore.

Today, 2-year survival following kidney transplantation among those aged 65 and older is approximately 90%, based on data from 7,823 patients who were transplanted in 2009-2011, in contrast to about 80% among 1,153 who were transplanted in 1991-1993. And, older adults who do receive kidney transplants have almost double the survival benefit, compared with those who remain on the waiting list. "We’re transplanting more older adults, and they’re doing better," Dr. Segev said

Nevertheless, about 300,000 adults aged 65 years and older are currently on the waiting list for donor kidneys, and there is evidence that these individuals are referred for transplantation less often than younger individuals with chronic kidney disease. In another study from Dr. Segev’s group, national registry data on 6,988 Medicare recipients (aged 65 and older) of a first kidney transplant in 1999-2006 were compared with those of 128,850 older adults with end-stage renal disease in those same years who did not have absolute or relative contraindications to transplantation (J. Am. Geriatr. Soc. 2012;60:1-7).

Of the 11,756 who would be considered "excellent" candidates for transplantation (defined as greater than 87% predicted 3-year posttransplantation survival, corresponding to the top 20% of transplanted older adults), just 24% had access to transplantation and 13% actually received a kidney transplant. It was estimated that 11% of these candidates would have identified a suitable live donor had they been referred for kidney transplantation. "Those who should be transplanted are getting referred at an extremely low rate," Dr. Segev commented.

One way to counter the belief that donor kidneys are "wasted" on adults with lower remaining life expectancy is to consider kidney options that may not be appropriate for younger recipients, including "expanded criteria" donor kidneys, older living donors, and a special category designated by the Centers for Disease Control and Prevention as "infectious disease risk" donors.

"Expanded criteria" donors (ECDs) include those who are aged 60 years and older, or age 50-59 with two of the following three criteria: hypertension, stroke as the cause of death, or terminal creatinine greater than 1.5 mg/dL. There is a separate recipient waiting list for ECDs, of which "many are great kidneys," Dr. Segev said.

In a review of 142,907 first-time deceased-donor kidney registrants who were reported to UNOS (United Network for Organ Sharing) between 2003 and 2008, Dr. Segev and his associates found that just 67% of adults older than 65 years who were predicted to benefit from ECDs were listed for them, with huge variation (0% to 100%) by center (Am. J. Transplant. 2010;10:802-9).

Older living donors are another potential – but underutilized – source of donor kidneys for their peers. Among 219 healthy adults aged 70 and older who have donated kidneys at 80 U.S. transplantation centers, graft loss in the recipients was significantly higher than were matched 50- to 59-year-old, live-donor allografts, but were similar to matched, nonextended-criteria, 50- to 59-year-old, deceased-donor allografts. Mortality among the older living kidney donors was no higher than that among healthy matched controls, and in fact they lived longer (Clin. J. Am. Soc. Nephrol. 2011;6:2887-93).

"The study showed that donors do well and recipients do well, particularly older recipients. ... Many older adults have a social network of other older adults who would be willing to donate if they knew it was possible," Dr. Segev said.

Another source of alternative donor organs that might be appropriate for selected elderly patients are those from the Centers for Disease Control and Prevention’s "Infectious Risk Donors." These include men who have sex with men (MSM), injection drug users, hemophiliacs, prostitutes, those exposed to HIV, those who have had sex with anyone in the previous categories, and incarcerated individuals. Such donors account for nearly 10% of the donor pool, and their organs are discarded more often than other donor organs.

"It seems wasteful to discard these. There should be someone on the list who would benefit from them, even with higher infectious risk. The real diseases we worry about – HIV and HCV [hepatitis C virus] – take years for sequelae to develop," Dr. Segev said.

In two separate studies, the risk of infection from such an organ per 10,000 donors during the "window period" prior to positive test results for injection drug users was 4.9 for HIV and 32.4 for HCV. For MSM, those risks were 4.2 and 3.5, respectively, and for commercial sex workers, 2.7 and 12.3, respectively. The others incurred lower risks (Am. J. Transplant. 2011;1176-87; 11:1188-200).

New data from Dr. Segev’s group suggest that the risk of a poor outcome (defined as 33% or more of the year after the kidney transplantation that was spent hospitalized or dying) among older transplant recipients increases by an adjusted odds ratio of 1.42 per 10 years. Years on pretransplantation dialysis also was a significant predictor (1.11), whereas the receipt of a live donor organ was protective (0.59).

In all, the risks of kidney transplantation for older adults include the upfront risks of surgery, particularly among those with comorbidities; the risk of immunosuppression; and the ongoing need for medical follow-up. But the benefits can include longer survival and improved quality of life, Dr. Segev said.

Dr. Segev disclosed that he is a consultant, scientific advisor, and speaker for Sanofi.

NATIONAL HARBOR, MD – The prognosis for older adult kidney transplant recipients has improved dramatically in recent years, and these individuals deserve to be referred for transplantation more often than they currently are, according to transplant surgeon, Dr. Dorry Segev.

Dr. Segev pointed to data from his own and other studies, showing that not only have survival rates among older adult kidney recipients improved, but the use of donor kidneys from older adults can in some cases be considered acceptable for younger recipients.

"What we knew about transplantation 20 years ago is completely different now. Immunosuppression agents are better, clinical protocols are better. ...Those aged 65 and older can have pretty good outcomes with transplantation," said Dr. Segev of the department of surgery at Johns Hopkins University, Baltimore.

Today, 2-year survival following kidney transplantation among those aged 65 and older is approximately 90%, based on data from 7,823 patients who were transplanted in 2009-2011, in contrast to about 80% among 1,153 who were transplanted in 1991-1993. And, older adults who do receive kidney transplants have almost double the survival benefit, compared with those who remain on the waiting list. "We’re transplanting more older adults, and they’re doing better," Dr. Segev said

Nevertheless, about 300,000 adults aged 65 years and older are currently on the waiting list for donor kidneys, and there is evidence that these individuals are referred for transplantation less often than younger individuals with chronic kidney disease. In another study from Dr. Segev’s group, national registry data on 6,988 Medicare recipients (aged 65 and older) of a first kidney transplant in 1999-2006 were compared with those of 128,850 older adults with end-stage renal disease in those same years who did not have absolute or relative contraindications to transplantation (J. Am. Geriatr. Soc. 2012;60:1-7).

Of the 11,756 who would be considered "excellent" candidates for transplantation (defined as greater than 87% predicted 3-year posttransplantation survival, corresponding to the top 20% of transplanted older adults), just 24% had access to transplantation and 13% actually received a kidney transplant. It was estimated that 11% of these candidates would have identified a suitable live donor had they been referred for kidney transplantation. "Those who should be transplanted are getting referred at an extremely low rate," Dr. Segev commented.

One way to counter the belief that donor kidneys are "wasted" on adults with lower remaining life expectancy is to consider kidney options that may not be appropriate for younger recipients, including "expanded criteria" donor kidneys, older living donors, and a special category designated by the Centers for Disease Control and Prevention as "infectious disease risk" donors.

"Expanded criteria" donors (ECDs) include those who are aged 60 years and older, or age 50-59 with two of the following three criteria: hypertension, stroke as the cause of death, or terminal creatinine greater than 1.5 mg/dL. There is a separate recipient waiting list for ECDs, of which "many are great kidneys," Dr. Segev said.

In a review of 142,907 first-time deceased-donor kidney registrants who were reported to UNOS (United Network for Organ Sharing) between 2003 and 2008, Dr. Segev and his associates found that just 67% of adults older than 65 years who were predicted to benefit from ECDs were listed for them, with huge variation (0% to 100%) by center (Am. J. Transplant. 2010;10:802-9).

Older living donors are another potential – but underutilized – source of donor kidneys for their peers. Among 219 healthy adults aged 70 and older who have donated kidneys at 80 U.S. transplantation centers, graft loss in the recipients was significantly higher than were matched 50- to 59-year-old, live-donor allografts, but were similar to matched, nonextended-criteria, 50- to 59-year-old, deceased-donor allografts. Mortality among the older living kidney donors was no higher than that among healthy matched controls, and in fact they lived longer (Clin. J. Am. Soc. Nephrol. 2011;6:2887-93).

"The study showed that donors do well and recipients do well, particularly older recipients. ... Many older adults have a social network of other older adults who would be willing to donate if they knew it was possible," Dr. Segev said.

Another source of alternative donor organs that might be appropriate for selected elderly patients are those from the Centers for Disease Control and Prevention’s "Infectious Risk Donors." These include men who have sex with men (MSM), injection drug users, hemophiliacs, prostitutes, those exposed to HIV, those who have had sex with anyone in the previous categories, and incarcerated individuals. Such donors account for nearly 10% of the donor pool, and their organs are discarded more often than other donor organs.

"It seems wasteful to discard these. There should be someone on the list who would benefit from them, even with higher infectious risk. The real diseases we worry about – HIV and HCV [hepatitis C virus] – take years for sequelae to develop," Dr. Segev said.

In two separate studies, the risk of infection from such an organ per 10,000 donors during the "window period" prior to positive test results for injection drug users was 4.9 for HIV and 32.4 for HCV. For MSM, those risks were 4.2 and 3.5, respectively, and for commercial sex workers, 2.7 and 12.3, respectively. The others incurred lower risks (Am. J. Transplant. 2011;1176-87; 11:1188-200).

New data from Dr. Segev’s group suggest that the risk of a poor outcome (defined as 33% or more of the year after the kidney transplantation that was spent hospitalized or dying) among older transplant recipients increases by an adjusted odds ratio of 1.42 per 10 years. Years on pretransplantation dialysis also was a significant predictor (1.11), whereas the receipt of a live donor organ was protective (0.59).

In all, the risks of kidney transplantation for older adults include the upfront risks of surgery, particularly among those with comorbidities; the risk of immunosuppression; and the ongoing need for medical follow-up. But the benefits can include longer survival and improved quality of life, Dr. Segev said.

Dr. Segev disclosed that he is a consultant, scientific advisor, and speaker for Sanofi.

NATIONAL HARBOR, MD. – Facebook is being used to directly solicit living kidney donors, and some aspects of that use raise privacy and ethical issues, according to Dr. Alex Chang.

The social networking site has been widely praised since its May 1 launch of a program allowing users to add organ donor status to their timelines and facilitating users’ linking to their state or national organ donor registries. However, its use for directly soliciting living donors raises issues of concern that organ transplant programs need to recognize and respond to, said Dr. Chang, a nephrology fellow at Loyola University Medical Center, Maywood, Ill.

"What I like about what Facebook has done is that it increases organ donation awareness and makes it personal. ... Facebook, I think, will dramatically increase organ registries if this is implemented well. However, careful consideration of the risks and benefits should be taken prior to being a living kidney donor," Dr. Chang said in an interview at a meeting sponsored by the National Kidney Foundation.

In their poster presentation at the meeting, Dr. Chang and his colleagues analyzed 144 English-language pages on Facebook devoted to soliciting a living kidney donor for a specific person in need. Potential organ recipients ranged in age from 2 to 69 years, and included all racial and ethnic groups and blood types. Of the pages for which the relationships between the page creator and the patient could be determined, 37% were created by the patients themselves, 31% by their children, and 32% by other family or friends.

People posted a range of information from one-sentence requests to explicit medical histories, as well as photographs of family and of the patient receiving hemodialysis.

"Much more careful consideration of the ethical implications of using social media is needed. The privacy issue is huge. ... Many people do not realize the vast amount of information that can be garnered from their Facebook pages, and when you add medical information to that, the risk is increased more," he said.

Although the contribution of Facebook in soliciting donors couldn’t be determined, 30% of the pages reported that donors had been tested, and 12% that a kidney transplant had been received. Individuals for whom donors were tested were significantly more likely to be white and to have more than 50 posts by others on their sites.

The risks of kidney donation were mentioned by 5% of the pages; only 11% mentioned associated costs. "I thought that was pretty astonishing since you are asking a very serious favor of your friends and family and/or strangers, and there is little mention of the actual risks and costs. Oftentimes, donors are caught unaware of certain financial costs such as missing 2 weeks of work and [the fact that] the long-term consequences of living kidney donation are still not totally certain. I believe this deserves fair mention if this method of media is being used for this purpose," Dr. Chang said.

Also of concern: Offers to sell kidneys were posted on 3% of pages.

"In my view I think it is premature to promote using Facebook to solicit living kidney donors. However it is happening and will continue to happen. I think that transplant programs have to recognize this and come up with plans on how to deal with social media–mediated living kidney transplant."

Dr. Chang said he had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Facebook is being used to directly solicit living kidney donors, and some aspects of that use raise privacy and ethical issues, according to Dr. Alex Chang.

The social networking site has been widely praised since its May 1 launch of a program allowing users to add organ donor status to their timelines and facilitating users’ linking to their state or national organ donor registries. However, its use for directly soliciting living donors raises issues of concern that organ transplant programs need to recognize and respond to, said Dr. Chang, a nephrology fellow at Loyola University Medical Center, Maywood, Ill.

"What I like about what Facebook has done is that it increases organ donation awareness and makes it personal. ... Facebook, I think, will dramatically increase organ registries if this is implemented well. However, careful consideration of the risks and benefits should be taken prior to being a living kidney donor," Dr. Chang said in an interview at a meeting sponsored by the National Kidney Foundation.

In their poster presentation at the meeting, Dr. Chang and his colleagues analyzed 144 English-language pages on Facebook devoted to soliciting a living kidney donor for a specific person in need. Potential organ recipients ranged in age from 2 to 69 years, and included all racial and ethnic groups and blood types. Of the pages for which the relationships between the page creator and the patient could be determined, 37% were created by the patients themselves, 31% by their children, and 32% by other family or friends.

People posted a range of information from one-sentence requests to explicit medical histories, as well as photographs of family and of the patient receiving hemodialysis.

"Much more careful consideration of the ethical implications of using social media is needed. The privacy issue is huge. ... Many people do not realize the vast amount of information that can be garnered from their Facebook pages, and when you add medical information to that, the risk is increased more," he said.

Although the contribution of Facebook in soliciting donors couldn’t be determined, 30% of the pages reported that donors had been tested, and 12% that a kidney transplant had been received. Individuals for whom donors were tested were significantly more likely to be white and to have more than 50 posts by others on their sites.

The risks of kidney donation were mentioned by 5% of the pages; only 11% mentioned associated costs. "I thought that was pretty astonishing since you are asking a very serious favor of your friends and family and/or strangers, and there is little mention of the actual risks and costs. Oftentimes, donors are caught unaware of certain financial costs such as missing 2 weeks of work and [the fact that] the long-term consequences of living kidney donation are still not totally certain. I believe this deserves fair mention if this method of media is being used for this purpose," Dr. Chang said.

Also of concern: Offers to sell kidneys were posted on 3% of pages.

"In my view I think it is premature to promote using Facebook to solicit living kidney donors. However it is happening and will continue to happen. I think that transplant programs have to recognize this and come up with plans on how to deal with social media–mediated living kidney transplant."

Dr. Chang said he had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Facebook is being used to directly solicit living kidney donors, and some aspects of that use raise privacy and ethical issues, according to Dr. Alex Chang.

The social networking site has been widely praised since its May 1 launch of a program allowing users to add organ donor status to their timelines and facilitating users’ linking to their state or national organ donor registries. However, its use for directly soliciting living donors raises issues of concern that organ transplant programs need to recognize and respond to, said Dr. Chang, a nephrology fellow at Loyola University Medical Center, Maywood, Ill.

"What I like about what Facebook has done is that it increases organ donation awareness and makes it personal. ... Facebook, I think, will dramatically increase organ registries if this is implemented well. However, careful consideration of the risks and benefits should be taken prior to being a living kidney donor," Dr. Chang said in an interview at a meeting sponsored by the National Kidney Foundation.

In their poster presentation at the meeting, Dr. Chang and his colleagues analyzed 144 English-language pages on Facebook devoted to soliciting a living kidney donor for a specific person in need. Potential organ recipients ranged in age from 2 to 69 years, and included all racial and ethnic groups and blood types. Of the pages for which the relationships between the page creator and the patient could be determined, 37% were created by the patients themselves, 31% by their children, and 32% by other family or friends.

People posted a range of information from one-sentence requests to explicit medical histories, as well as photographs of family and of the patient receiving hemodialysis.

"Much more careful consideration of the ethical implications of using social media is needed. The privacy issue is huge. ... Many people do not realize the vast amount of information that can be garnered from their Facebook pages, and when you add medical information to that, the risk is increased more," he said.

Although the contribution of Facebook in soliciting donors couldn’t be determined, 30% of the pages reported that donors had been tested, and 12% that a kidney transplant had been received. Individuals for whom donors were tested were significantly more likely to be white and to have more than 50 posts by others on their sites.

The risks of kidney donation were mentioned by 5% of the pages; only 11% mentioned associated costs. "I thought that was pretty astonishing since you are asking a very serious favor of your friends and family and/or strangers, and there is little mention of the actual risks and costs. Oftentimes, donors are caught unaware of certain financial costs such as missing 2 weeks of work and [the fact that] the long-term consequences of living kidney donation are still not totally certain. I believe this deserves fair mention if this method of media is being used for this purpose," Dr. Chang said.

Also of concern: Offers to sell kidneys were posted on 3% of pages.

"In my view I think it is premature to promote using Facebook to solicit living kidney donors. However it is happening and will continue to happen. I think that transplant programs have to recognize this and come up with plans on how to deal with social media–mediated living kidney transplant."

Dr. Chang said he had no relevant financial disclosures.

NATIONAL HARBOR, MD. – Contrary to current practice trends, evidence suggests that kidney dialysis can – and perhaps should – be delayed in older adults with chronic kidney disease.

"Older adults, like their younger counterparts, should not initiate dialysis on the basis of [estimated glomerular filtration] alone, but can wait to delay dialysis initiation until more traditional clinical indicators appear, such as fluid overload that can’t be managed with diuretics; uremic symptoms which interfere with quality of life; or electrolyte disturbances," said Dr. Manjula Kurella Tamura.

"An individualized approach to these decisions that accounts for the patient’s burden of symptoms and trajectory of kidney function decline is probably wise until more clinical trials are conducted in the older adult population," continued Dr. Tamura of the division of nephrology at Stanford (Calif.) University.

Two striking patterns have emerged over time. First, in all age groups, dialysis is being initiated at a higher estimated glomerular filtration rate (eGFR) today, compared with a decade ago, which is generally viewed as representing earlier initiation of dialysis over time (Kidney Int. 2009;76:257-61).

Secondl older patients are initiating dialysis earlier in the course of kidney disease than are younger patients. This was true one decade ago and is even more so today, when more than 50% of patients older than age 75 years begin dialysis with an eGFR greater than 10 mL/min per 1.73 m² (Arch. Intern. Med. 2011;171:1663-9).

One rationale often cited for starting older patients on dialysis sooner is that they have a lower tolerance for uremia. However, Dr. Tamura said, "I looked back through the literature to find out where this idea came from. It certainly has a lot of face validity, but is there evidence that it’s true? I couldn’t find it. I just kept seeing it repeated over and over, that older patients need to start sooner. But I couldn’t find an explanation."

And in fact, increasing evidence suggests that the opposite may be true. In one study of 112 adults older than age 75 with GFR of 5-7 mL/min, there were no differences in survival between those who were randomized to dialysis or those on a very low protein diet with delayed dialysis initiation (median follow-up, 26.5 months). There also were no differences between the two groups in the causes of death, and there were actually fewer hospitalizations and total hospital days in the diet group (Am. J. Kidney Dis. 2007;49:569-80).

That study excluded patients with diabetes, an ejection fraction less than 30%, urine protein excretion greater than 3 g/day, active malignancy, and uremic symptoms, she noted.

Subsequently, the multicenter IDEAL (Initiating Dialysis Early and Late) study was conducted in Australia and New Zealand, in which 828 adults (mean age, 60 years) with progressive chronic kidney disease were randomized to "early start" of dialysis, with planned initiation when eGFR was 10.0-14.0 mL/min, or "late start," at eGFR of 5.0-7.0 mL/min. Earlier initiation of dialysis was permitted based on the discretion of the treating physician (N. Engl. J. Med. 2010;363:609-19).

Owing to the development of symptoms, 75% of the "late start" group was initiated on dialysis with an eGFR of greater than 7.0 mL/min, with a mean of 9.8 mL/min and a median delay of 6 months, compared with the "early start" group, who initiated dialysis with a mean eGFR of 12 mL/min. There were no differences in survival between the early and late groups (median follow-up, 3.6 years). Subgroup analysis showed that there also were no differences between the early vs. late groups among patients older than 60 years, Dr. Tamura said.

The IDEAL authors concluded that "with careful clinical management, dialysis may be delayed until either the GFR drops below 7 mL/min or more traditional clinical indicators for the initiation of dialysis are present."

However, the question of whether the IDEAL findings can be applied to older patients prompted controversy, given that the patients included in the study were younger than the overall dialysis population and relatively healthy, and therefore less susceptible to the potential complications of later initiation of dialysis (N. Engl. J. Med. 2010;363:2368).

To address that issue, Dr. Tamura and her associates retrospectively examined the timing of initiation of dialysis in a population of 2,402 nursing home residents who initiated dialysis in 1998-2000. The median eGFR at the time of dialysis initiation was 9.8 mL/min. The likelihood of earlier dialysis initiation (eGFR of 15 mL/min or greater) was associated with having one or more signs and symptoms of volume overload, cognitive decline, increased dependence in activities of daily living, and weight loss. However, those factors altogether accounted for only 31% of the early dialysis initiations (Am. J. Kidney Dis. 2010;56:1117-26).

"Certainly, the factors that contribute to early dialysis initiation are complex and may not always be clinical. But again, it makes you think that perhaps some of these patients are not started early because they have symptoms, but for other reasons, and perhaps it’s just the nervousness of the nephrologist caring for a very frail patient," she commented.

Indeed, urgent indications accounted for just 10% of the patients in the late-start arm of the IDEAL study who ended up initiating dialysis at greater than the target eGFR, with "uremia" and "physician discretion" accounting for 80%. However, Dr. Tamura pointed out, the uremic syndrome can be difficult to diagnose in elderly patients with other chronic conditions. No biomarker is sufficiently specific, and symptoms of uremia can overlap with other conditions. For example, nausea may result from diabetic gastroparesis, fatigue may be from cardiopulmonary disease or depression, and cognitive impairment might be cause by medications or dementia.

Moreover, conditions commonly observed in advanced chronic kidney disease – such as malnutrition, low functional status, pruritis, and restless leg syndrome – not always improve with dialysis initiation.

Also complicating the decision of when to initiate dialysis in the elderly is the fact that estimated equations for GFR tend to be less accurate in the elderly due to sarcopenia and fluid retention, and that acute kidney injury is more common in older patients, she said.

Given all this, Dr. Tamura advises that it is appropriate to delay dialysis initiation in older asymptomatic adults with an eGFR greater than 10 mL/min. As for when it is appropriate to initiate dialysis, "there are still more questions than answers. Clinical judgment will continue to guide practice, but hopefully symptom burden and patient preferences will have a stronger influence."

Dr. Tamura reported having no conflicts of interest.

NATIONAL HARBOR, MD. – Contrary to current practice trends, evidence suggests that kidney dialysis can – and perhaps should – be delayed in older adults with chronic kidney disease.

"Older adults, like their younger counterparts, should not initiate dialysis on the basis of [estimated glomerular filtration] alone, but can wait to delay dialysis initiation until more traditional clinical indicators appear, such as fluid overload that can’t be managed with diuretics; uremic symptoms which interfere with quality of life; or electrolyte disturbances," said Dr. Manjula Kurella Tamura.

"An individualized approach to these decisions that accounts for the patient’s burden of symptoms and trajectory of kidney function decline is probably wise until more clinical trials are conducted in the older adult population," continued Dr. Tamura of the division of nephrology at Stanford (Calif.) University.

Two striking patterns have emerged over time. First, in all age groups, dialysis is being initiated at a higher estimated glomerular filtration rate (eGFR) today, compared with a decade ago, which is generally viewed as representing earlier initiation of dialysis over time (Kidney Int. 2009;76:257-61).

Secondl older patients are initiating dialysis earlier in the course of kidney disease than are younger patients. This was true one decade ago and is even more so today, when more than 50% of patients older than age 75 years begin dialysis with an eGFR greater than 10 mL/min per 1.73 m² (Arch. Intern. Med. 2011;171:1663-9).

One rationale often cited for starting older patients on dialysis sooner is that they have a lower tolerance for uremia. However, Dr. Tamura said, "I looked back through the literature to find out where this idea came from. It certainly has a lot of face validity, but is there evidence that it’s true? I couldn’t find it. I just kept seeing it repeated over and over, that older patients need to start sooner. But I couldn’t find an explanation."

And in fact, increasing evidence suggests that the opposite may be true. In one study of 112 adults older than age 75 with GFR of 5-7 mL/min, there were no differences in survival between those who were randomized to dialysis or those on a very low protein diet with delayed dialysis initiation (median follow-up, 26.5 months). There also were no differences between the two groups in the causes of death, and there were actually fewer hospitalizations and total hospital days in the diet group (Am. J. Kidney Dis. 2007;49:569-80).

That study excluded patients with diabetes, an ejection fraction less than 30%, urine protein excretion greater than 3 g/day, active malignancy, and uremic symptoms, she noted.

Subsequently, the multicenter IDEAL (Initiating Dialysis Early and Late) study was conducted in Australia and New Zealand, in which 828 adults (mean age, 60 years) with progressive chronic kidney disease were randomized to "early start" of dialysis, with planned initiation when eGFR was 10.0-14.0 mL/min, or "late start," at eGFR of 5.0-7.0 mL/min. Earlier initiation of dialysis was permitted based on the discretion of the treating physician (N. Engl. J. Med. 2010;363:609-19).

Owing to the development of symptoms, 75% of the "late start" group was initiated on dialysis with an eGFR of greater than 7.0 mL/min, with a mean of 9.8 mL/min and a median delay of 6 months, compared with the "early start" group, who initiated dialysis with a mean eGFR of 12 mL/min. There were no differences in survival between the early and late groups (median follow-up, 3.6 years). Subgroup analysis showed that there also were no differences between the early vs. late groups among patients older than 60 years, Dr. Tamura said.

The IDEAL authors concluded that "with careful clinical management, dialysis may be delayed until either the GFR drops below 7 mL/min or more traditional clinical indicators for the initiation of dialysis are present."

However, the question of whether the IDEAL findings can be applied to older patients prompted controversy, given that the patients included in the study were younger than the overall dialysis population and relatively healthy, and therefore less susceptible to the potential complications of later initiation of dialysis (N. Engl. J. Med. 2010;363:2368).

To address that issue, Dr. Tamura and her associates retrospectively examined the timing of initiation of dialysis in a population of 2,402 nursing home residents who initiated dialysis in 1998-2000. The median eGFR at the time of dialysis initiation was 9.8 mL/min. The likelihood of earlier dialysis initiation (eGFR of 15 mL/min or greater) was associated with having one or more signs and symptoms of volume overload, cognitive decline, increased dependence in activities of daily living, and weight loss. However, those factors altogether accounted for only 31% of the early dialysis initiations (Am. J. Kidney Dis. 2010;56:1117-26).

"Certainly, the factors that contribute to early dialysis initiation are complex and may not always be clinical. But again, it makes you think that perhaps some of these patients are not started early because they have symptoms, but for other reasons, and perhaps it’s just the nervousness of the nephrologist caring for a very frail patient," she commented.

Indeed, urgent indications accounted for just 10% of the patients in the late-start arm of the IDEAL study who ended up initiating dialysis at greater than the target eGFR, with "uremia" and "physician discretion" accounting for 80%. However, Dr. Tamura pointed out, the uremic syndrome can be difficult to diagnose in elderly patients with other chronic conditions. No biomarker is sufficiently specific, and symptoms of uremia can overlap with other conditions. For example, nausea may result from diabetic gastroparesis, fatigue may be from cardiopulmonary disease or depression, and cognitive impairment might be cause by medications or dementia.

Moreover, conditions commonly observed in advanced chronic kidney disease – such as malnutrition, low functional status, pruritis, and restless leg syndrome – not always improve with dialysis initiation.

Also complicating the decision of when to initiate dialysis in the elderly is the fact that estimated equations for GFR tend to be less accurate in the elderly due to sarcopenia and fluid retention, and that acute kidney injury is more common in older patients, she said.

Given all this, Dr. Tamura advises that it is appropriate to delay dialysis initiation in older asymptomatic adults with an eGFR greater than 10 mL/min. As for when it is appropriate to initiate dialysis, "there are still more questions than answers. Clinical judgment will continue to guide practice, but hopefully symptom burden and patient preferences will have a stronger influence."

Dr. Tamura reported having no conflicts of interest.

NATIONAL HARBOR, MD. – Contrary to current practice trends, evidence suggests that kidney dialysis can – and perhaps should – be delayed in older adults with chronic kidney disease.

"Older adults, like their younger counterparts, should not initiate dialysis on the basis of [estimated glomerular filtration] alone, but can wait to delay dialysis initiation until more traditional clinical indicators appear, such as fluid overload that can’t be managed with diuretics; uremic symptoms which interfere with quality of life; or electrolyte disturbances," said Dr. Manjula Kurella Tamura.

"An individualized approach to these decisions that accounts for the patient’s burden of symptoms and trajectory of kidney function decline is probably wise until more clinical trials are conducted in the older adult population," continued Dr. Tamura of the division of nephrology at Stanford (Calif.) University.

Two striking patterns have emerged over time. First, in all age groups, dialysis is being initiated at a higher estimated glomerular filtration rate (eGFR) today, compared with a decade ago, which is generally viewed as representing earlier initiation of dialysis over time (Kidney Int. 2009;76:257-61).

Secondl older patients are initiating dialysis earlier in the course of kidney disease than are younger patients. This was true one decade ago and is even more so today, when more than 50% of patients older than age 75 years begin dialysis with an eGFR greater than 10 mL/min per 1.73 m² (Arch. Intern. Med. 2011;171:1663-9).

One rationale often cited for starting older patients on dialysis sooner is that they have a lower tolerance for uremia. However, Dr. Tamura said, "I looked back through the literature to find out where this idea came from. It certainly has a lot of face validity, but is there evidence that it’s true? I couldn’t find it. I just kept seeing it repeated over and over, that older patients need to start sooner. But I couldn’t find an explanation."

And in fact, increasing evidence suggests that the opposite may be true. In one study of 112 adults older than age 75 with GFR of 5-7 mL/min, there were no differences in survival between those who were randomized to dialysis or those on a very low protein diet with delayed dialysis initiation (median follow-up, 26.5 months). There also were no differences between the two groups in the causes of death, and there were actually fewer hospitalizations and total hospital days in the diet group (Am. J. Kidney Dis. 2007;49:569-80).

That study excluded patients with diabetes, an ejection fraction less than 30%, urine protein excretion greater than 3 g/day, active malignancy, and uremic symptoms, she noted.

Subsequently, the multicenter IDEAL (Initiating Dialysis Early and Late) study was conducted in Australia and New Zealand, in which 828 adults (mean age, 60 years) with progressive chronic kidney disease were randomized to "early start" of dialysis, with planned initiation when eGFR was 10.0-14.0 mL/min, or "late start," at eGFR of 5.0-7.0 mL/min. Earlier initiation of dialysis was permitted based on the discretion of the treating physician (N. Engl. J. Med. 2010;363:609-19).

Owing to the development of symptoms, 75% of the "late start" group was initiated on dialysis with an eGFR of greater than 7.0 mL/min, with a mean of 9.8 mL/min and a median delay of 6 months, compared with the "early start" group, who initiated dialysis with a mean eGFR of 12 mL/min. There were no differences in survival between the early and late groups (median follow-up, 3.6 years). Subgroup analysis showed that there also were no differences between the early vs. late groups among patients older than 60 years, Dr. Tamura said.

The IDEAL authors concluded that "with careful clinical management, dialysis may be delayed until either the GFR drops below 7 mL/min or more traditional clinical indicators for the initiation of dialysis are present."

However, the question of whether the IDEAL findings can be applied to older patients prompted controversy, given that the patients included in the study were younger than the overall dialysis population and relatively healthy, and therefore less susceptible to the potential complications of later initiation of dialysis (N. Engl. J. Med. 2010;363:2368).

To address that issue, Dr. Tamura and her associates retrospectively examined the timing of initiation of dialysis in a population of 2,402 nursing home residents who initiated dialysis in 1998-2000. The median eGFR at the time of dialysis initiation was 9.8 mL/min. The likelihood of earlier dialysis initiation (eGFR of 15 mL/min or greater) was associated with having one or more signs and symptoms of volume overload, cognitive decline, increased dependence in activities of daily living, and weight loss. However, those factors altogether accounted for only 31% of the early dialysis initiations (Am. J. Kidney Dis. 2010;56:1117-26).

"Certainly, the factors that contribute to early dialysis initiation are complex and may not always be clinical. But again, it makes you think that perhaps some of these patients are not started early because they have symptoms, but for other reasons, and perhaps it’s just the nervousness of the nephrologist caring for a very frail patient," she commented.

Indeed, urgent indications accounted for just 10% of the patients in the late-start arm of the IDEAL study who ended up initiating dialysis at greater than the target eGFR, with "uremia" and "physician discretion" accounting for 80%. However, Dr. Tamura pointed out, the uremic syndrome can be difficult to diagnose in elderly patients with other chronic conditions. No biomarker is sufficiently specific, and symptoms of uremia can overlap with other conditions. For example, nausea may result from diabetic gastroparesis, fatigue may be from cardiopulmonary disease or depression, and cognitive impairment might be cause by medications or dementia.

Moreover, conditions commonly observed in advanced chronic kidney disease – such as malnutrition, low functional status, pruritis, and restless leg syndrome – not always improve with dialysis initiation.

Also complicating the decision of when to initiate dialysis in the elderly is the fact that estimated equations for GFR tend to be less accurate in the elderly due to sarcopenia and fluid retention, and that acute kidney injury is more common in older patients, she said.

Given all this, Dr. Tamura advises that it is appropriate to delay dialysis initiation in older asymptomatic adults with an eGFR greater than 10 mL/min. As for when it is appropriate to initiate dialysis, "there are still more questions than answers. Clinical judgment will continue to guide practice, but hopefully symptom burden and patient preferences will have a stronger influence."

Dr. Tamura reported having no conflicts of interest.

NATIONAL HARBOR, MD.  – De novo dipstick proteinuria accurately predicted acute kidney injury among 328 critically ill septic patients, a retrospective chart study has shown.

With sepsis, inflammation results in increased capillary permeability to plasma proteins, manifesting in an increased excretion of albumin into the urine. Because the production of creatinine from the muscle is reduced in septic patients, relying on changes in serum creatinine could delay the diagnosis of this acute kidney injury (AKI), according to Dr. Javier Neyra.

Photo courtesy Dr. Javier Neyra

"It is highly important to identify biomarkers that are sensitive, specific, and provide timely and early diagnosis of acute kidney injury before substantial damage has already been done. ... De novo dipstick proteinuria represents a simple, inexpensive biomarker in sepsis with predictive power for AKI," said Dr. Neyra of the Henry Ford Hospital, Detroit.

Charts from a total of 2,252 patients admitted to the intensive care unit for severe sepsis between January 2004 and July 2011 were analyzed retrospectively. Patients with a baseline serum creatinine level greater than 1.5 mg/dL, the presence of dipstick proteinuria within 3 months of the admission date, or common causes of false-positive dipstick tests such as urinary tract infection or gross hematuria were excluded. Of the remaining 470 patients, 328 had undergone dipstick testing on admission. Of those, 46% (152) had dipstick proteinuria.

Serum creatinine increased by at least 0.3 mg/dL in 210 (64%) patients within the first 72 hours of admission, signifying the first stage of acute kidney injury. In this group, new-onset dipstick proteinuria was found in 114 (54%) patients, for a positive predictive value of 75%. Dipstick proteinuria was found in 91 (55%) of 166 patients who met the Acute Kidney Injury Network criteria for AKI, for a positive predictive value of 60%.

After adjustment for age, sex, race, comorbidities, hemodynamic status, and other variables, de novo dipstick proteinuria at the time of admission independently predicted AKI with an odds ratio of 2.3 (95% confidence interval, 1.4-3.8), Dr. Neyra reported in a poster at a meeting sponsored by the National Kidney Foundation.

In an interview, Dr. Neyra explained that such information identifies septic patients who would benefit from more careful monitoring of kidney function and hemodynamic stability. In addition, in those patients it would be important to avoid nephrotoxic agents such as aminoglycoside antibiotics and nonsteroidal anti-inflammatory agents, as well as exposure to contrast material unless it was absolutely necessary.

"The dipstick is a test that you already have in your hospital that you can utilize. It’s simple, inexpensive, and it’s already there," he said.

Dr. Neyra stated that he had no relevant financial disclosures.

NATIONAL HARBOR, MD.  – De novo dipstick proteinuria accurately predicted acute kidney injury among 328 critically ill septic patients, a retrospective chart study has shown.

With sepsis, inflammation results in increased capillary permeability to plasma proteins, manifesting in an increased excretion of albumin into the urine. Because the production of creatinine from the muscle is reduced in septic patients, relying on changes in serum creatinine could delay the diagnosis of this acute kidney injury (AKI), according to Dr. Javier Neyra.

Photo courtesy Dr. Javier Neyra

"It is highly important to identify biomarkers that are sensitive, specific, and provide timely and early diagnosis of acute kidney injury before substantial damage has already been done. ... De novo dipstick proteinuria represents a simple, inexpensive biomarker in sepsis with predictive power for AKI," said Dr. Neyra of the Henry Ford Hospital, Detroit.

Charts from a total of 2,252 patients admitted to the intensive care unit for severe sepsis between January 2004 and July 2011 were analyzed retrospectively. Patients with a baseline serum creatinine level greater than 1.5 mg/dL, the presence of dipstick proteinuria within 3 months of the admission date, or common causes of false-positive dipstick tests such as urinary tract infection or gross hematuria were excluded. Of the remaining 470 patients, 328 had undergone dipstick testing on admission. Of those, 46% (152) had dipstick proteinuria.

Serum creatinine increased by at least 0.3 mg/dL in 210 (64%) patients within the first 72 hours of admission, signifying the first stage of acute kidney injury. In this group, new-onset dipstick proteinuria was found in 114 (54%) patients, for a positive predictive value of 75%. Dipstick proteinuria was found in 91 (55%) of 166 patients who met the Acute Kidney Injury Network criteria for AKI, for a positive predictive value of 60%.

After adjustment for age, sex, race, comorbidities, hemodynamic status, and other variables, de novo dipstick proteinuria at the time of admission independently predicted AKI with an odds ratio of 2.3 (95% confidence interval, 1.4-3.8), Dr. Neyra reported in a poster at a meeting sponsored by the National Kidney Foundation.

In an interview, Dr. Neyra explained that such information identifies septic patients who would benefit from more careful monitoring of kidney function and hemodynamic stability. In addition, in those patients it would be important to avoid nephrotoxic agents such as aminoglycoside antibiotics and nonsteroidal anti-inflammatory agents, as well as exposure to contrast material unless it was absolutely necessary.

"The dipstick is a test that you already have in your hospital that you can utilize. It’s simple, inexpensive, and it’s already there," he said.

Dr. Neyra stated that he had no relevant financial disclosures.

NATIONAL HARBOR, MD.  – De novo dipstick proteinuria accurately predicted acute kidney injury among 328 critically ill septic patients, a retrospective chart study has shown.

With sepsis, inflammation results in increased capillary permeability to plasma proteins, manifesting in an increased excretion of albumin into the urine. Because the production of creatinine from the muscle is reduced in septic patients, relying on changes in serum creatinine could delay the diagnosis of this acute kidney injury (AKI), according to Dr. Javier Neyra.

Photo courtesy Dr. Javier Neyra

"It is highly important to identify biomarkers that are sensitive, specific, and provide timely and early diagnosis of acute kidney injury before substantial damage has already been done. ... De novo dipstick proteinuria represents a simple, inexpensive biomarker in sepsis with predictive power for AKI," said Dr. Neyra of the Henry Ford Hospital, Detroit.

Charts from a total of 2,252 patients admitted to the intensive care unit for severe sepsis between January 2004 and July 2011 were analyzed retrospectively. Patients with a baseline serum creatinine level greater than 1.5 mg/dL, the presence of dipstick proteinuria within 3 months of the admission date, or common causes of false-positive dipstick tests such as urinary tract infection or gross hematuria were excluded. Of the remaining 470 patients, 328 had undergone dipstick testing on admission. Of those, 46% (152) had dipstick proteinuria.

Serum creatinine increased by at least 0.3 mg/dL in 210 (64%) patients within the first 72 hours of admission, signifying the first stage of acute kidney injury. In this group, new-onset dipstick proteinuria was found in 114 (54%) patients, for a positive predictive value of 75%. Dipstick proteinuria was found in 91 (55%) of 166 patients who met the Acute Kidney Injury Network criteria for AKI, for a positive predictive value of 60%.

After adjustment for age, sex, race, comorbidities, hemodynamic status, and other variables, de novo dipstick proteinuria at the time of admission independently predicted AKI with an odds ratio of 2.3 (95% confidence interval, 1.4-3.8), Dr. Neyra reported in a poster at a meeting sponsored by the National Kidney Foundation.

In an interview, Dr. Neyra explained that such information identifies septic patients who would benefit from more careful monitoring of kidney function and hemodynamic stability. In addition, in those patients it would be important to avoid nephrotoxic agents such as aminoglycoside antibiotics and nonsteroidal anti-inflammatory agents, as well as exposure to contrast material unless it was absolutely necessary.

"The dipstick is a test that you already have in your hospital that you can utilize. It’s simple, inexpensive, and it’s already there," he said.

Dr. Neyra stated that he had no relevant financial disclosures.