Incorporating Geriatric Assessment into a Nephrology Clinic: Preliminary Data from Two Models of Care.

Older adults with advanced chronic kidney disease (CKD) experience functional impairment that can complicate CKD management. Failure to recognize functional impairment may put these individuals at risk of further functional decline, nursing home placement, and missed opportunities for timely goals-of-care conversations. Routine geriatric assessment could be a useful tool for identifying older adults with CKD who are at risk of functional decline and provide contextual information to guide clinical decision-making. Two innovative programs were implemented in the Veterans Health Administration that incorporate geriatric assessment into a nephrology visit. In one program, a geriatrician embedded in a nephrology clinic used standardized geriatric assessment tools with individuals with CKD aged 70 and older (Comprehensive Geriatric Assessment for CKD) (CGA-4-CKD). In the second program, a nephrology clinic used comprehensive appointments for individuals aged 75 and older to conduct geriatric assessments and CKD care (Renal Silver). Data on 68 veterans who had geriatric assessments through these programs between November 2013 and May 2015 are reported. In CGA-4-CKD, difficulty with one or more activities of daily living (ADLs), history of falls, and cognitive impairment were each found in 27.3% of participants. ADL difficulty was found in 65.7%, falls in 28.6%, and cognitive impairment in 51.6% of participants in Renal Silver. Geriatric assessment guided care processes in 45.4% (n = 15) of veterans in the CGA-4-CKD program and 37.1% (n = 13) of those in Renal Silver. Findings suggest there is a significant burden of functional impairment in older adults with CKD. Knowledge of this impairment is applicable to CKD management.

Proliferative C4 Dense Deposit Disease, Acute Thrombotic Microangiopathy, a Monoclonal Gammopathy, and Acute Kidney Failure.

Dense deposit disease (DDD) is a rare form of glomerulonephritis that has recently been reclassified under the broad group of C3 glomerulopathy, which also includes C3 glomerulonephritis. C3 glomerulopathy is characterized by predominant C3 staining on immunofluorescence microscopy and dysregulation of the alternative complement pathway. We present a case of DDD concurrent with acute thrombotic microangiopathy (TMA) in a 54-year-old white man. The patient presented with acute kidney injury, and a kidney biopsy showed segmental highly electron-dense intramembranous deposits and large rounded mesangial electron-dense deposits consistent with DDD and coexisting glomerular and vascular thrombosis consistent with concurrent acute TMA. However, immunofluorescence microscopy did not show C3 staining in nonsclerotic glomeruli, excluding C3 DDD. Rather, there was dense staining for C4d along the glomerular capillaries, suggesting C4 DDD. Activity of the alternative complement pathway was normal. To our knowledge, this is the first reported case of C4 DDD concurrent with TMA. One previous case report of C4 DDD had been reported, though in a teenage girl. These 2 cases suggest that C4 DDD is a rare entity and should be distinguished from the C3 glomerulopathies.

Electrolytes in the aging.

The elderly population in the United States continues to grow and is expected to double by 2050. With aging, there are degenerative changes in many organs and the kidney is no exception. After 40 years of age, there is an increase in cortical glomerulosclerosis and a decline in both glomerular filtration rate and renal plasma flow. These changes may be associated with an inability to excrete a concentrated or a dilute urine, ammonium, sodium, or potassium. Hypernatremia and hyponatremia are the most common electrolyte abnormalities found in the elderly and both are associated with a high mortality. Under normal conditions, the elderly are able to maintain water and electrolyte balance, but this may be jeopardized by an illness, a decline in cognitive ability, and with certain medications. Therefore, it is important to be aware of the potential electrolyte abnormalities in the elderly that can arise under these various conditions to prevent adverse outcomes.

Geriatric nephrology: old or new subspecialty.

In the 1980s geriatric nephrology was introduced as a subspecialty in anticipation of the increased number of elderly and very elderly people during the 21st century. There has been more clinical research dedicated to geriatric nephrology, education on the subspecialty has been implemented at national and university level, and funds for career development have been instituted over the past two decades. Our treatment of the elderly and very elderly patients seems to be more focused on their biologic age rather than chronologic age; they undergo diagnostic tests such as kidney biopsies and are candidates for kidney transplant. Although great strides have been made in the assimilation of geriatrics into nephrology more has to be done. This article examines the areas of research that encompass geriatric nephrology and clinic observations applicable to the care of the geriatric population.

Cholecalciferol (vitamin D3) therapy and vitamin D insufficiency in patients with chronic kidney disease: a randomized controlled pilot study.

OBJECTIVE: To investigate the efficacy of cholecalciferol (vitamin D3) in raising serum 25-hydroxyvitamin D (25[OH)]D) levels and reducing parathyroid hormone (PTH) levels in patients with chronic kidney disease (CKD). METHODS: In this double-blind, randomized controlled pilot study, participants with CKD stage 3 and 4 (estimated glomerular filtration rate, 15-59 mL/min/1.73 m2), vitamin D insufficiency (serum 25[OH]D <30 ng/mL), and serum intact PTH levels >70 pg/mL were randomly assigned to receive either 50 000 IU of cholecalciferol or placebo once weekly for 12 weeks. Primary outcomes (25[OH]D and PTH levels) were measured at baseline, week 6, and week 12. Secondary outcomes (1,25-dihydroxvitamin D and bone turnover markers) were measured at baseline and week 12. Because of skewed data distribution, statistical analyses were performed on a logarithmic scale. The difference between the group means was exponentiated to provide the geometric mean ratio. A linear mixed model using an unstructured variance-covariance matrix was used to examine change in the primary and secondary outcomes over time. RESULTS: Geometric mean serum 25(OH)D concentrations of the study groups were similar at baseline (P = .77). At week 6, a significant difference between the treatment and placebo groups was detected (P = .001); this difference was maintained at week 12 (P = .002). Among cholecalciferol-treated participants, serum 25(OH)D concentration increased on average from 17.3 ng/mL (95% confidence interval [CI], 11.8-25.2) at baseline to 49.4 ng/mL (95% CI, 33.9-72.0) at week 12. As-treated analysis indicated a trend toward lower PTH levels among cholecalciferol-treated participants (P = .07). CONCLUSION: Weekly cholecalciferol supplementation appears to be an effective treatment to correct vitamin D status in patients with CKD.