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Contents Preface ix Edgar V. Lerma and Mitchell H. Rosner Anatomic and Physiologic Changes of the Aging Kidney 555 Zeina Karam and Jennifer Tuazon Aging is associated with structural and functional changes in the kidney. Structural changes include glomerulosclerosis, thickening of the base- ment membrane, increase in mesangial matrix, tubulointerstitial fibrosis and arteriosclerosis. Glomerular filtration rate is maintained until the fourth decade of life, after which it declines. Parallel reductions in renal blood flow occur with redistribution of blood flow from the cortex to the medulla. Other functional changes include an increase in glomerular basement per- meability and decreased ability to dilute or concentrate urine. Acute Kidney Injury in the Elderly 565 Mitchell H. Rosner Most patients who develop acute kidney injury (AKI) are older than 65 years. Specific structural and functional changes that occur in the aging kidney predispose the elderly patient to AKI. This risk is further com- pounded by comorbid conditions, polypharmacy, and the need for inva- sive procedures. When AKI does occur, it is associated with significant morbidity and mortality. Although morbidity and mortality increases with advancing age, many elderly patients can survive AKI and do well. Thus, decision making should be thoughtful and individualized, and not depen- dent on age. Whenever possible, preventive approaches should be pur- sued to lessen the burden of AKI. An Update on Glomerular Disease in the Elderly 579 Richard J. Glassock Examination of urinary sediment for dysmorphic erythrocytes as a diagnos- tic tool in glomerular disease is important. The atypical clinical features of acute and chronic glomerular disease in the elderly should be remem- bered. The common causes of nephrotic syndrome need to be remem- bered in patients with edema and marked proteinuria. The predilection of the elderly to develop rapidly progressive glomerulonephritis needs to be appreciated. The development of glomerular disease caused by an underlying neoplastic process also needs to be remembered. Effective treatment regimens are available to ameliorate the adverse consequences of acute, progressive, and chronic glomerular disease in the geriatric population. Hypertension in the Elderly: Unique Challenges and Management 593 Faruk Turgut, Yusuf Yesil, Rasheed A. Balogun, and Emaad M. Abdel-Rahman Elderly individuals, worldwide, are on the rise, posing new challenges to care providers. Hypertension is highly prevalent in elderly individuals, Updates in Geriatric Nephrology

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Updates in Geriatric Nephrology

Contents

Preface ix

Edgar V. Lerma and Mitchell H. Rosner

Anatomic and Physiologic Changes of the Aging Kidney 555

Zeina Karam and Jennifer Tuazon

Aging is associated with structural and functional changes in the kidney.Structural changes include glomerulosclerosis, thickening of the base-ment membrane, increase in mesangial matrix, tubulointerstitial fibrosisand arteriosclerosis. Glomerular filtration rate is maintained until the fourthdecade of life, after which it declines. Parallel reductions in renal blood flowoccur with redistribution of blood flow from the cortex to the medulla.Other functional changes include an increase in glomerular basement per-meability and decreased ability to dilute or concentrate urine.

Acute Kidney Injury in the Elderly 565

Mitchell H. Rosner

Most patients who develop acute kidney injury (AKI) are older than 65years. Specific structural and functional changes that occur in the agingkidney predispose the elderly patient to AKI. This risk is further com-pounded by comorbid conditions, polypharmacy, and the need for inva-sive procedures. When AKI does occur, it is associated with significantmorbidity and mortality. Although morbidity and mortality increases withadvancing age, many elderly patients can survive AKI and do well. Thus,decision making should be thoughtful and individualized, and not depen-dent on age. Whenever possible, preventive approaches should be pur-sued to lessen the burden of AKI.

An Update on Glomerular Disease in the Elderly 579

Richard J. Glassock

Examination of urinary sediment for dysmorphic erythrocytes as a diagnos-tic tool in glomerular disease is important. The atypical clinical features ofacute and chronic glomerular disease in the elderly should be remem-bered. The common causes of nephrotic syndrome need to be remem-bered in patients with edema and marked proteinuria. The predilectionof the elderly to develop rapidly progressive glomerulonephritis needs tobe appreciated. The development of glomerular disease caused by anunderlying neoplastic process also needs to be remembered. Effectivetreatment regimens are available to ameliorate the adverse consequencesof acute, progressive, and chronic glomerular disease in the geriatricpopulation.

Hypertension in the Elderly: Unique Challenges and Management 593

Faruk Turgut, Yusuf Yesil, Rasheed A. Balogun, and Emaad M. Abdel-Rahman

Elderly individuals, worldwide, are on the rise, posing new challenges tocare providers. Hypertension is highly prevalent in elderly individuals,

Contentsvi

and multiple challenges face care providers while managing it. In additionto treating hypertension, the physician must treat other modifiable cardio-vascular risk factors in patients with or without diabetes mellitus or chronickidney disease to reduce cardiovascular events and mortality. This reviewdiscusses some of the unique characteristics of high blood pressure in theelderly and provides an overview of the challenges facing care providers,as well as the current recommendations for management of hypertensionin the elderly.

Chronic Kidney Disease in the Elderly 611

Thin Thin Maw and Linda Fried

Chronic kidney disease (CKD) is increasingly being recognized as a dis-ease of elderly individuals. In recent years the definition and categorizationof kidney disease has been standardized. There are concerns that thisstandardization has led to an increase in the number of older individualslabeled as having CKD. This article addresses the definitions of CKD,recently published revised CKD stages with risk stratifications, and limita-tions of using formulas to assess renal function in the elderly. Also dis-cussed are management of common risk factors of progression CKD,nonrenal-related outcomes, prognosis of CKD in older individuals, and cri-teria for referral to nephrology.

Dialysis Therapies in Older Patients with End-Stage Renal Disease 625

Tuschar Malavade, Ahmed Sokwala, and Sarbjit Vanita Jassal

Each year a large number of older individuals with advanced renal diseaseare started on chronic dialysis therapy. Life expectancy is estimated atbetween 2 and 4 years depending on age, comorbidity, and intensity ofmedical care required in the weeks around the dialysis start time. Survivorsremain at high risk of ongoing morbidity. Regarding quality of life, manyolder patients express regret over having opted for chronic dialysis therapyand subsequently choose to withdraw from treatment, whereas manyothers maintain a quality of life similar to that of age-matched peers. Earlyassessment and ongoing comprehensive geriatric assessment isrecommended.

Decision Making in Elderly Patients with Advanced Kidney Disease 641

Holly M. Koncicki and Mark A. Swidler

Because the fastest-growing group of patients undergoing dialysis isolder than 75 years, geriatricians will be more involved in decisionsregarding the appropriate treatment of end-stage renal disease. Athoughtful approach to shared decision making regarding dialysis or non-dialysis medical therapy (NDMT) includes consideration of medical indi-cations, patient preferences, quality of life, and contextual features.Determination of prognosis and expected performance on dialysis basedon disease trajectories and assessment of functional age should beshared with patients and families. The Renal Physician Association’sguidelines on shared decision making in dialysis offer recommendationsto help with dialysis or NDMT decisions.

Contents vii

Drug Dosing in Elderly Patients with Chronic Kidney Disease 657

Jessica Lassiter, William M. Bennett, and Ali J. Olyaei

As the elderly population in the United States increases, health care pro-fessionals need to be aware of potential age-related changes that affectmedication prescribing. Increased emphasis on careful patient assess-ment and safety can reduce the incidence of adverse events related tomedications.

Transplantation in the Elderly Patient 707

Douglas Scott Keith

During the last 2 decades, the number of kidney transplants performed inthe candidates older than 65 years has grown dramatically. For selectedgeriatric patients with end-stage kidney failure, kidney transplantationhas emerged as a potential option for treatment of their end organ failure.Aging is associated with functional changes to the immune system knownas immunosenescence, and this age-related decline in immune functionhas important implications for immunosuppression in this subgroup of kid-ney transplant recipients.

Slowing the Aging Process 721

Jocelyn Wiggins and Markus Bitzer

Research into the aging process is very new. For many years aging wasthought to be the natural and inevitable consequence of a life of wearand tear. The idea that aging could be influenced by the genetic codeand had a modifiable biologic component is less than 20 years old. Duringthis time, aging has come to be understood as a complex biologic processcontrolled by signaling pathways and transcription factors. Similar atti-tudes pervade the field of nephrology. Whether a decline in renal functionwith age represents normal aging or kidney disease is the subject of muchdebate.

Index 731