class: RWH_bg_title # .black[Kidney Disease in the Elderly] ### MOE SpR teaching .RWH_footnote_title[ .RWH_footer_bold[ Rob Hunter | @renalrob ] ] .RWH_footnote_right_title[ .RWH_footer_bold[ 26th Oct 2023 ] ] ??? Slides created with [xaringan](https://github.com/yihui/xaringan). --- # Sucking eggs - normal ageing *vs.* CKD - limited physiological reserve - realistic medicine *vs.* therapeutic nihilism - evidence gap - side-effects - multi-morbidity - polypharmacy - age-specific pathologies ??? Should read [Canadian study](https://pubmed.ncbi.nlm.nih.gov/34459844/) on fixed *vs* age-adapted CKD definition and accompanying editorial by [O'Hare](https://pubmed.ncbi.nlm.nih.gov/34459870/). In Alberta cohort of 80,000 adults, compared fixed eGFR threshold of 60 to define CKD with age-adapted thresholds (75 for under 40; 60 for under 65; 45 for over 65). Using a fixed threshold, 75% of CKD patients are over 65 and would be re-classified (as eGFR > 45 and uACR < 3). In this group, risks of ESKD and death were similar to non-CKD age-matched controls - suggesting fixed eGFR threshold leads to over-diagnosis of CKD in over 65s. --- # Overview - When caring for patients with with CKD on ward or in clinic, is there are role for `SLGT2i` in our cohort? - When should we be considering `K binders` in an acute setting (seems to be more widespread than we had initially expected?) - When should we be `referring AKI` to renal? (particularly given that many of our cohort less likely to be suitable for dialysis) - If we have patients with CKD who we `haven't referred` to the renal clinic, what should we be mindful of? .RWH_footnote_right[.RWH_footer_style[slides at: www.kidneyfish.net/talks/]] ??? What Aoife asked for... --- class: center, middle, inverse # .white[Case 1] ### 80F with T2DM and CKD --- # Case 1 This pleasant `80 year-old` with `T2DM` was on metformin (1g bd) and was recently started on `empagliflozin` (10 mg od) by the diabetic team at her annual review. Her HbA1c was 58. Her renal function has now dipped to `eGFR 40`. I have asked her to stop her losartan and empagliflozin. I have asked for a urine specimen for urinalysis. I wanted to check if you would also like us to stop her metformin? -- <br> > .red[What else would you like to know?] > .red[What would you do?] <br> > .red[Can SGLT2i be used safely in older adults (and frailty)?] > .red[What are the anticipated benefits of SGLT2i?] ??? Hypothetical case. SGLT2i now everyone's business (not just diabetes, renal...) Importance of albuminuria. Cr 100 to 113; uACR < 3. --- # Hot off the press...  .RWH_footnote_right[.RWH_footer_style[[Roddick *et al.* (2023)](https://pubmed.ncbi.nlm.nih.gov/37880609/)]] --- # Sucking eggs again  <br> Caution in extrapolating from RCTs that largely excluded frail, multi-morbid patients. But recognise likely significant benefit in heart failure. .RWH_footnote_right[.RWH_footer_style[[Roddick *et al.* (2023)](https://pubmed.ncbi.nlm.nih.gov/37880609/)]] ---  <br> We recommend (grade 1A) SGLT2i if T2DM and CKD with eGFR 20 -- 45. ??? Becoming increasingly complicated to navigate. How on earth to implement in elderly frail patient? --- # Case 1 This pleasant `80 year-old` with `T2DM` was on metformin (1g bd) and was recently started on `empagliflozin` (10 mg od) by the diabetic team at her annual review. Her HbA1c was 58. Her renal function has now dipped to `eGFR 40`. I have asked her to stop her losartan and empagliflozin. I have asked for a urine specimen for urinalysis. I wanted to check if you would also like us to stop her metformin? <br> > .red[Why was empagliflozin prescribed in the first place?] ??? Elderly patients with CKD die or get heart failure rather than ESKD. ---  .RWH_footnote_right[.RWH_footer_style[[Ravani *et al.* (2020)](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770736)]] ??? Cohort study in 4 million people in Canada (2002 - 2017). ---  .RWH_footnote_right[.RWH_footer_style[[O'Hare *et al.* (2007)](https://jasn.asnjournals.org/content/18/10/2758)]] ??? 200,000 US veterans. ---  .RWH_footnote_right[.RWH_footer_style[[Cardio-renal consortium meta-analysis (2022)](https://pubmed.ncbi.nlm.nih.gov/36351458/)]] ---  .RWH_footnote_right[.RWH_footer_style[[Roddick *et al.* (2023)](https://pubmed.ncbi.nlm.nih.gov/37880609/)]] --- # RRRs Broadly consistent across diabetic and non-diabetic populations: - CVS death = 10 % - CVS death or HF hospitalisation = 20 % - AKI = 20 % - progressive CKD = 40 % .RWH_footnote_right[.RWH_footer_style[[Cardio-renal consortium meta-analysis (2022)](https://pubmed.ncbi.nlm.nih.gov/36351458/)]] ??? Advantages of RRR approach: - easier to remember - can apply to individual patient (so CKD not treated as binary variable for example) ---  ??? See also [McRae et al. (2021)](https://pubmed.ncbi.nlm.nih.gov/33558333/) - comorbidity very common in CKD (in Scotland). ---  ---  ??? QRISK3 incorporates CKD (binary variable) and can cope with extremes of age. Presumed systolc 150 for purposes of this; other data all real. ASSIGN score = 48, which approximates to 48% risk over 10 yrs but probably a bit lower. QRISK3 = 33% risk over 10 yrs. ---  --- # Safety data in older adults? Ages in DAPA-CKD and EMPA KIDNEY approx 62 +/- 12 yrs. [Zhuo et al., AJKD 2021](https://pubmed.ncbi.nlm.nih.gov/34762974/): cohort study in adults over 66 yrs with T2DM (n = 140,000). New users of SLGT2i matched to new users of DPP4i and GLP1RAs. Reduced AKI with SGLT2i (RRR 0.2 - 0.3). [Pratley et al., Lancet Healthy Longev 2023](https://pubmed.ncbi.nlm.nih.gov/37003273/): secondary analysis of VERTIS CV (RCT of ertugliflozin in T2DM with high CVS risk). Compared under 65, 65 - 75 (n = 8000), over 75 (n = 900). Broadly similar results across age-groups. <br> Very little data in frailty / significant multimorbidity. --- class: center, middle, inverse # .white[Case 2] ### 76F with AKI --- # Case 2 `79F` admitted with `pneumonia`. Smoker, EtOH XS, hip replacement, HTN on amlodipine and atenolol. Getting worse after 7 days in hospital. Not for ITU. SCr 60 > 80 > 200 > 550 mcM K 5.9 o/e: - ABP 110/60 (after period of systolic in 90s) - increasing O2 requirement (4L/min nasal) - JVP elevated - anuric - IVI at 250 ml/hr (already 3L +ve in 24 hrs) -- <br> > .red[Would you give sodium zirconium cyclosillicate?] > .red[Would you refer to renal?... ...and why?] ??? Hypothetical case. Kussmaul breathing. pH 7.2 H 59 HCO3 12 PaCO2 3.7 BE -16 AG 33; ketones 1.4; lactate 0.9 Biopsy showed ATN. Three weeks later: - still HD-dep on HDU - line infection - HIT (peri-arrest) --- # Lokelma https://edren.org/ren/handbook/prescribing-handbook/ https://edren.org/ren/handbook/unithdbk/fluids-and-electrolytes/ Sodium zirconium cyclosillicate (Lokelma) now on East Region Formulary for use under specialist supervision. Highly selective K binder; works throughout GI tract; onset within 1 hr; sodium load. `Acute use`: - K > 6 mM - not getting dialysis - renal recovery expected within 72 hrs `Chronic use`: - attending renal clinic (or cardiology) - CKD3B-5 - uPCR > 50 - unable to acheive optimal RASi - unprovoked hyperK despite optimisation of TCO2, diuretics, diet... ??? K threshold in dialysis patients is 5.5 mM. Lokelma approved by SMC for acute and chronic use (with restrictions). On formulary for acute and chronic use in renal patients (but not yet for chronic use in heart failure). Retrospective PACS2 no longer required and discussion with renal not mandated but probably still advisable until we are all familiar and renal protocols all up online (should be imminent). Patiromer (Valtessa) now approved by SMC for acute and chronic use - but not on Formulary. Less selective, works in distal colon, delayed onset (6 hrs), hypoMg, constipation. Will probably add to Formulary as back-up in case of supply issues. --- # Lokelma - practice points - avoid in bowel obstruction - should be under renal supervision - prescribe on HEPMA (10g every 8 hrs for 3 days) - anticipate 1 mM reduction by 24 hrs - switch to maintenance dose (5 -- 10 g od -- bd) when K < 5.5 mM - daily U&Es - usually no more than 7 days; definitely stop before discharge - patients who do not fit pre-approved criteria can use emergency PACS2 route --- # Hyperkalaemia https://edren.org/ren/handbook/unithdbk/fluids-and-electrolytes/ <br> Remember: - diet may not be effective - treat constipation? - diuretics - bicarbonate - trimethoprim, heparin... ??? Theory that constipation may predispose to hyperK. I think unproven. 90% K absorption in the small intestine. K secreted into the colon through pathways upregalated in CKD. Thery is that slower transit times may increase K absorption. See https://pubmed.ncbi.nlm.nih.gov/32043026/ and https://pubmed.ncbi.nlm.nih.gov/37127307/. --- # Case 2 `79F` admitted with `pneumonia`. Smoker, EtOH XS, hip replacement, HTN on amlodipine and atenolol. Getting worse after 7 days in hospital. Not for ITU. SCr 60 > 80 > 200 > 550 mcM K 5.9 o/e: - ABP 110/60 (after period of systolic in 90s) - increasing O2 requirement (4L/min nasal) - JVP elevated - anuric - IVI at 250 ml/hr (already 3L +ve in 24 hrs) <br> > .red[Would you give sodium zirconium cyclosillicate?] > .red[Would you refer to renal?... ...and why?] --- # Renal team in CKD in elderly - diagnosis (vasculitis, nephrotic syndrome, myeloma...) - prognostication / advance care planning - iron and epo - Edren - RIE.RenalAdvice@luht.scot.nhs.uk --- # Overview - When caring for patients with with CKD on ward or in clinic, is there are role for `SLGT2i` in our cohort? - When should we be considering `K binders` in an acute setting (seems to be more widespread than we had initially expected?) - When should we be `referring AKI` to renal? (particularly given that many of our cohort less likely to be suitable for dialysis) - If we have patients with CKD who we `haven't referred` to the renal clinic, what should we be mindful of? .RWH_footnote_right[.RWH_footer_style[slides at: www.kidneyfish.net/talks/]] --- # Take-home messages - most elderly patients with CKD will die before progressing to ESKD - therefore focus on CVS risk reduction - SGLT2i helpful for many elderly patients... - ...but uncertainty in frailty (I like RRR approach) - Lokelma useful acutely (and chronically) in selected cases - d/w renal - do please talk to us!  .RWH_footnote_right[.RWH_footer_style[slides at: www.kidneyfish.net/talks/]]