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Health & Medicine for Senior Citizens

Much Higher Rate of Untreated Kidney Failure Found Among Older People

Incidence of advanced kidney disease in the elderly may be substantially underestimated by rates of treated kidney failure alone

June 19, 2012 - A study involving almost 2 million adults in Canada to determine whether age is associated with the likelihood of treatment for kidney failure found the rate of progression to untreated kidney failure was considerably higher among older adults – the elderly in particular.

In the report to be published in the June 20 issue of the Journal of the American Medical Association (JAMA), the study authors explain what led to their study.

“Studies of the association among age, kidney function, and clinical outcomes have reported that elderly patients are less likely to develop end-stage renal disease (ESRD), compared with younger patients, and are more likely to die than to progress to kidney failure, even at the lowest levels of estimated glomerular filtration rate (eGFR; flow rate of filtered fluid through a kidney),” they explain in the article.


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Previous studies have defined kidney failure as those receiving long-term dialysis, which reflects both disease progression and a treatment decision.

“Because it is plausible that the likelihood of initiating long-term dialysis among individuals with kidney failure varies by age, earlier studies may provide an incomplete picture of the burden of advanced kidney disease in older adults, based on the incidence of long-term dialysis alone,” the researchers wrote.

The study to determine whether age is associated with the likelihood of treated kidney failure (renal replacement therapy: receipt of long-term dialysis or kidney transplantation), untreated kidney failure, and all-cause mortality, was conducted by Brenda R. Hemmelgarn, M.D., Ph.D., of the University of Calgary, Alberta, Canada, and colleagues.

The study included 1,816,824 adults in Alberta, Canada, who had outpatient eGFR measured between May 2002 and March 2008, with a baseline eGFR of 15 mL/min/1.73 m2 or higher and who did not require renal replacement therapy at the beginning of the study.

The primary outcome measures for the study were adjusted rates of treated kidney failure, untreated kidney failure (progression to eGFR <15 mL/min/1.73 m2 without renal replacement therapy), and death.

During a median (midpoint) follow-up of 4.4 years,
   ● 97,451 (5.4 percent) of study participants died,
   ● 3,295 (0.18 percent) developed treated kidney failure, and
   ● 3,116 (0.17 percent) developed untreated kidney failure.

The researchers found that within each eGFR stratum, adjusted rates of death increased with increasing age.

Also, within each eGFR stratum, rates of treated kidney failure were consistently higher among the youngest age group. “For example, in the lowest eGFR stratum (15-29 mL/min/1.73 m2), adjusted rates of treated kidney failure were more than 10-fold higher among the youngest (18-44 years) compared with the oldest (85 years or older) groups,” the authors write.

The opposite results were evident for untreated kidney failure. The risk of untreated kidney failure increased with lower vs. higher eGFR categories, and this association was stronger with increasing age.

“For the lowest eGFR stratum (15-29 mL/min/1.73 m2), adjusted rates of untreated kidney failure were more than 5-fold higher among the oldest age stratum (85 years or older) compared with the youngest age stratum (18-44 years).”

Rates of kidney failure overall (treated and untreated combined) demonstrated less variation across age groups.

The researchers write that their results suggest that the incidence of advanced kidney disease in the elderly may be substantially underestimated by rates of treated kidney failure alone.

“These findings have important implications for clinical practice and decision making; coupled with the finding that many older adults with advanced chronic kidney disease [CKD] are not adequately prepared for dialysis, these results suggest a need to prioritize the assessment and recognition of CKD progression among older adults.

“Our findings also imply that clinicians should offer dialysis to older adults who are likely to benefit from it - and should offer a positive alternative to dialysis in the form of conservative management (including end-of-life care when appropriate) for patients who are unlikely to benefit from (or prefer not to receive) long-term dialysis.

10 things you can do to
protect your kidneys

and help family and friends protect theirs



If you have diabetes, high blood pressure, or a family history of kidney failure, get your blood and urine checked for kidney disease.



At your next family gathering, talk to loved ones with diabetes and high blood pressure about getting tested for kidney disease.


Learn how to keep your kidneys healthy.


Educate your faith-based community about the kidney connection.


Use spices, herbs and sodium-free seasonings in place of salt.


For those recently diagnosed with kidney disease, find out about the basics of kidney disease and what it means for you.


Watch videos to hear about the different treatment options for kidney failure.


Health care professionals: Learn more about two key markers for chronic kidney disease: urine albumin and estimated glomerular filtration rate.


Become an organ donor.


"Like" the NKDEP's Make the Kidney Connection Facebook page.


“Given the large number of older adults with severe CKD, these results also highlight the need for more proactive identification of older adults with CKD, assessment of their symptom burden, and development of appropriate management strategies.

“Finally, our study demonstrates the need to better understand the clinical significance of untreated kidney failure, the factors that influence dialysis initiation decisions in older adults, and the importance of a shared decision making process for older adults with advanced CKD.”

Editorial: This debate can no longer be avoided

This important scientific and ethical debate can no longer be avoided, for both individual and societal good,” write Manjula Kurella Tamura, M.D., M.P.H., and Wolfgang C. Winkelmayer, M.D., M.P.H., Sc.D., of the Stanford University School of Medicine in an editorial. Dr. Winkelmayer is also Contributing Editor of JAMA

They note that the study “highlights a potentially sizeable unmeasured burden of untreated kidney failure among older adults.”

And, they add, “It is of paramount importance to refine the current understanding of what constitutes appropriate treatment for kidney failure, which factors influence the decision-making process, and which methods are optimal for aligning treatment plans with patient goals and prognosis. Finding the right balance between overtreatment and undertreatment is challenging but necessary.”

What Your Kidneys Do

You have two kidneys. They are bean-shaped, and about the size of a fist. They are located in the middle of your back, on the left and right sides of your spine, just below your rib cage. Their main job is to filter extra water and wastes out of your blood and make urine. They also help control blood pressure and make hormones that your body needs to stay healthy.

About Kidney Disease



By National Kidney Disease Education Program

Chronic kidney disease - called kidney disease here for short - is a condition in which the small blood vessels in the kidneys are damaged, making the kidneys unable to do their job. Waste then builds up in the blood, harming the body.

Kidney disease is most often caused by diabetes or high blood pressure.
Diabetes and high blood pressure damage the blood vessels in the kidneys, so the kidneys are not able to filter the blood as well as they used to. Usually this damage happens slowly, over many years. As more and more blood vessels are damaged, the kidneys eventually stop working.

Other risk factors for kidney disease are cardiovascular (heart) disease and a family history of kidney failure. If you have any of these risk factors, you should get tested for kidney disease.

Early kidney disease has no symptoms
That means you can’t feel that you have it. In fact, you might feel just fine until your kidneys have almost stopped working. Don’t wait for symptoms. Blood and urine tests are the only way to know if you have kidney disease. A blood test measures your GFR and a urine test checks for protein. Learn more about tests for kidney disease.

Kidney disease can be treated if detected early.
The right treatment can help prevent further kidney damage and slow down kidney disease. The earlier kidney disease is found, the sooner you can take medications, called ACE inhibitors or ARBs, and other steps that can keep your kidneys healthy longer. Learn more about how to keep your kidneys healthy.

Kidney disease is progressive.
Kidney disease does not go away. Instead, it usually gets worse over time. Kidney disease can turn into kidney failure, at which point dialysis or a kidney transplant is needed. Kidney disease can also lead to heart disease. Learn more about what happens if your kidneys fail.

Take the first step
If you are at risk, get your blood and urine checked for kidney disease.

NKDEP is an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), U.S. Department of Health & Human Services (DHHS) ...More information

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