Guidelines for management of older patients with chronic kidney disease stage 3b or higher

Chronic kidney disease (CKD) is a worldwide public health problem, with adverse outcomes of kidney failure, cardiovascular disease (CVD), and premature death. A simple definition and classification of kidney disease is necessary for international development and implementation of clinical practice guidelines. Kidney Disease: Improving Global Outcomes (KDIGO) conducted a survey and sponsored a controversies conference to (1) provide a clear understanding to both the nephrology and nonnephrology communities of the evidence base for the definition and classification recommended by Kidney Disease Quality Outcome Initiative (K/DOQI), (2) develop global consensus for the adoption of a simple definition and classification system, and (3) identify a collaborative research agenda and plan that would improve the evidence base and facilitate implementation of the definition and classification of CKD.

In November 2016 , European Renal Best Practice has issued the Guideline for management of older patients with chronic kidney disease stage 3b or higher (eGFR <45 mL/min/1.73 m²).

Following are its major recommendations :

General Approach to Older Patients with Advanced Chronic Kidney Disease (CKD) (Estimated Glomerular Filtration Rate [eGFR ] <45 mL/min/1.73 m²)

Q1. What parameter should be used in older patients (a) to estimate kidney function and (b) for dose adaptation purposes?

• The Guideline Development Group (GDG) recommends using estimating equations that correct for differences in creatinine generation rather than plain serum creatinine measurements to assess kidney function in older patients (1A).


• The GDG recommends 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).


• The GDG recommends formal measurement of kidney function if more accurate and precise estimation of GFR is required (1B). The GDG suggests the use of Chronic Kidney Disease Epidemiology Collaboration creatinine-cystatin (CKD-EPI_Cr-Cyst) may be an acceptable alternative (2C).


• The GDG recommends taking account of kidney function when prescribing drugs whose active forms or metabolites are renally cleared (1A).


• The GDG suggests 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 uremia may necessitate use of different target levels of total drug concentration (2C).

Q2. What is the most reliable risk model score to predict progression of CKD in older patients with advanced CKD (eGFR <45 mL/min/1.73 m²)?

• The GDG recommends that the 4-variable Kidney Failure Risk Equation (KFRE) performs sufficiently well for use in older patients with advanced CKD and eGFR <45 mL/min/1.73 m² (1B).

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/1.73 m²)?

• The GDG suggests using the Bansal score to predict individual 5-year risk of death before end-stage kidney disease (ESKD) in non-frail older patients with CKD stage 3–5 (2B).


• The GDG suggests that in patients at low risk in the Bansal score, a score including the assessment of frailty as stated in question 4a be performed (2B).


• The GDG suggests that the Renal Epidemiology and Information Network (REIN) score be used to predict the risk for mortality in older patients with CKD stage 5 (2B).

Q4a: What is the best alternative method to assess functional decline in older and/or frail patients with advanced CKD?

• The GDG recommends 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 a more in-depth geriatric assessment and rehabilitation (1C).


• The GDG recommends most simple scores, including self-report scales and field tests (sit-to-stand [STS], gait speed or 6-min walk test) have comparable and sufficient discriminating power to identify patients with decreased functional status (1C).

Q4b: Are interventions aimed at increasing functional status in older patients with renal failure (eGFR <45 mL/min/ 1.73 m² or on dialysis) of benefit?

• The GDG recommends that exercise has a positive impact on the functional status of older patients with CKD stage 3b or higher (1C).


• The GDG suggests that exercise training be offered in a structured and individualized manner to avoid adverse events (2C).

Q5a: Which is the best alternative to evaluate nutritional status in older patients with advanced CKD 3b or higher (eGFR <45 mL/min/1.73 m²) or on dialysis?

• The GDG recommends 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/1.73m²) (1C).


• The GDG suggests that in older patients on hemodialysis (HD), a score including serum albumin, body mass index (BMI), serum creatinine/body surface area (BSA) and normalized protein nitrogen appearance [nPNA]) may be used to assess nutritional status (2D).

Q5b: Which interventions are effective in improving nutritional status in older/frail patients with advanced CKD (eGFR <45 mL/min/1.73 m²) or on dialysis?

• The GDG suggests a trial of structured dietary advice and support with the aim of improving nutritional status (2C).

Q6: What is the benefit of dialysis in frail and older patients?

• The GDG recommends the 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 (RRT) (see Figure 2 in the original guideline document).


• The GDG recommends that the option for conservative management (CM) be discussed during the shared decision-making process on different management options for ESKD (1D).


• The GDG recommends that the REIN score can be useful to stratify mortality risk of patients intending to start RRT (1C).

For more details click on the link : Farrington K, Covic A, Aucella F, Clyne N, de Vos L, Findlay A, Fouque D, Grodzicki T, Iyasere O, Jager KJ, Joosten H, Macias JF, Mooney A, Nitsch D, Stryckers M, Taal M, Tattersall J, Van Asselt D, Van den Noortgate N, Nistor I, Van Biesen W, ERBP Guideline Development Group. Clinical practice guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR <45 mL/min/1.73 m2). Nephrol Dial Transplant. 2016 Nov;31(suppl 2):ii1-ii66. [189 references] PubMed