老年慢性肾脏病并发症的特殊性
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摘要
随着全球人口老龄化加剧,老年慢性肾脏病(CKD)患病率逐年上升。由于老年人生理、心理、经济及社会地位变化,导致老年CKD具有其特殊性。老年CKD患者易合并糖尿病、高血压、心脑血管疾病等基础疾病,需药物治疗和手术治疗的可能性大,从而增加了肾脏损伤的机会;老年CKD患者易伴有生理功能及认知功能下降、抑郁、营养不良、骨质疏松及虚弱等情况,需进行综合评估;老年CKD患者发生并发症及死亡的风险高。需要对老年CKD患者进行个体化评估,根据死亡风险或进展风险的高低来决定是以保护肾脏的支持治疗为主还是支持治疗的同时积极准备肾脏替代治疗。应开展以老年CKD患者为对象的高质量临床研究,以为其提供更多诊治的循证依据。
As the global population ages,the incidence of chronic kidney disease (CKD) in the elderly has increased year by year. Due to changes in the physical,psychological,economic,and social status of the elderly,CKD in the elderly has its own particularity. Elderly patients with CKD are prone to diabetes,hypertension,cardiovascular and cerebrovascular diseases,and other basic diseases,and the possibility of drug treatment and surgical treatment is high,which increases the chance of kidney damage.Elderly patients with CKD are also prone to decline of physical and cognitive function, depression,malnutrition,osteoporosis,and weakness,which need comprehensive evaluation. Elderly patients with CKD have a high risk of complications and death. Thus it is necessary to evaluate the patients' conditions individually to predict the risk of death or progression to ESRD,so as to decide whether to mainly provide supportive treatment for protecting the kidney,or to provide supportive treatment together with preparing the renal replacement therapy. High-quality clinical studies in elderly CKD patients should be conducted to provide more evidence-based data for the diagnosis and treatment.
As the global population ages,the incidence of chronic kidney disease (CKD) in the elderly has increased year by year. Due to changes in the physical,psychological,economic,and social status of the elderly,CKD in the elderly has its own particularity. Elderly patients with CKD are prone to diabetes,hypertension,cardiovascular and cerebrovascular diseases,and other basic diseases,and the possibility of drug treatment and surgical treatment is high,which increases the chance of kidney damage.Elderly patients with CKD are also prone to decline of physical and cognitive function, depression,malnutrition,osteoporosis,and weakness,which need comprehensive evaluation. Elderly patients with CKD have a high risk of complications and death. Thus it is necessary to evaluate the patients' conditions individually to predict the risk of death or progression to ESRD,so as to decide whether to mainly provide supportive treatment for protecting the kidney,or to provide supportive treatment together with preparing the renal replacement therapy. High-quality clinical studies in elderly CKD patients should be conducted to provide more evidence-based data for the diagnosis and treatment.
引文
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[3]Zhang L,Wang F,Wang L,et al.Prevalence of chronic kidney disease in China:a cross-sectional survey[J].Lancet,2012,379(9818):815-822.
[4]National Kidney Foundation.KDOQI clinical practice guideline for diabetes and CKD:2012 update[J].Am J Kidney Dis,2012,60(5):850-886.
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[7]Andrassy KM.Comments on'KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease'[J].Kidney Int,2013,84(3):622-623.
[8]Earley A,Miskulin D,Lamb EJ,et al.Estimating equations for glomerular filtration rate in the era of creatinine standardization:a systematic review[J].Ann Intern Med,2012,156(11):785-795.
[9]Schold JD,Navaneethan SD,Jolly SE,et al.Implications of the CKD-EPI GFR estimation equation in clinical practice[J].Clin J Am Soc Nephrol,2011,6(3):497-504.
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[11]Peralta CA,Katz R,Sarnak MJ,et al.Cystatin C identifies chronic kidney disease patients at higher risk for complications[J].J Am Soc Nephrol,2011,22(1):147-155.
[12]Brook MO,Bottomley MJ,Mevada C,et al.Repeat testing is essential when estimating chronic kidney disease prevalence and associated cardiovascular risk[J].QJM,2012,105(3):247-255.
[13]Arora P,Jalal K,Gupta A,et al.Progression of kidney disease in elderly stage 3 and 4 chronic kidney disease patients[J].Int Urol Nephrol,2017,49(6):1033-1040.
[14]Johansson L,Fouque D,Bellizzi V,et al.As we grow old:nutritional considerations for older patients on dialysis[J].Nephrol Dial Transplant,2017,32(7):1127-1136.
[15]Brunori G,Viola BF,Parrinello G,et al.Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly:a prospective randomized multicenter controlled study[J].Am JKidney Dis,2007,49(5):569-580.
[16]Windahl K,Faxen Irving G,Almquist T,et al.Prevalence and risk of protein-energy wasting assessed by subjective global assessment in older adults with advanced chronic kidney disease:results from the EQUAL study[J].J Ren Nutr,2018,28(3):165-174.
[17]Farrington K,Covic A,Nistor I,et al.Clinical practice guideline on management of older patients with chronic kidney disease stage 3b or higher(e GFR<45 m L/min/1.73 m2):a summary document from the European Renal Best Practice Group[J].Nephrol Dial Transplant,2017,32(1):9-16.
[18]Slinin Y,Guo H,Gilbertson DT,et al.Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis[J].Am J Kidney Dis,2011,58(4):583-590.
[19]Fischer MJ,O'Hare AM.Epidemiology of hypertension in the elderly with chronic kidney disease[J].Adv Chronic Kidney Dis,2010,17(4):329-340.
[20]James PA,Oparil S,Carter BL,et al.2014 evidence-based guideline for the management of high blood pressure in adults:report from the panel members appointed to the Eighth Joint National Committee(JNC 8)[J].JAMA,2014,311(5):507-520.
[21]Kidney Disease:Improving Global Outcomes(KDIGO)CKDWork Group.KDIGO clinical practice guideline for the management of blood pressure in chronic kidney disease[J].Kidney Int Suppl,2012,2:337-414.
[22]中国医师协会肾脏内科医师分会,中国中西医结合学会肾脏疾病专业委员会.中国肾性高血压管理指南2016[J].中华医学杂志,2017,97(20):1547-1555.
[23]Carey RM,Whelton PK,2017 ACC/AHA Hypertension Guideline Writing Committee.Prevention,detection,evaluation,and management of high blood pressure in adults:synopsis of the2017 American College of Cardiology/American Heart Association Hypertension Guideline[J].Ann Intern Med,2018,168(5):351-358.
[24]Ogurtsova K,da Rocha Fernandes JD,Huang Y,et al.IDFdiabetes atlas:global estimates for the prevalence of diabetes for2015 and 2040[J].Diabetes Res Clin Pract,2017,128:40-50.
[25]Robles NR,Felix FJ,Fernandez-Berges D,et al.Prevalence of abnormal urinary albumin excretion in elderly people:a Spanish survey[J].Int Urol Nephrol,2013,45(2):553-560.
[26]Russo GT,De Cosmo S,Viazzi F,et al.Diabetic kidney disease in the elderly:prevalence and clinical correlates[J].BMCGeriatr,2018,18(1):38.
[27]Bertoluci MC,Moreira RO,Faludi A,et al.Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes:a position statement from the Brazilian Diabetes Society(SBD),the Brazilian Cardiology Society(SBC)and the Brazilian Endocrinology and Metabolism Society(SBEM)[J].Diabetol Metab Syndr,2017,9:53.
[28]Lipska KJ,Krumholz H,Soones T,et al.Polypharmacy in the aging patient:a review of glycemic control in older adults with type 2 diabetes[J].JAMA,2016,315(10):1034-1045.
[29]Tonelli M,Wiebe N,James MT,et al.A population-based cohort study defines prognoses in severe chronic kidney disease[J].Kidney Int,2018,93(5):1217-1226.
[30]Thomas B,Matsushita K,Abate KH,et al.Global cardiovascular and renal outcomes of reduced GFR[J].J Am Soc Nephrol,2017,28(7):2167-2179.
[31]James MT,Tonelli M,Ghali WA,et al.Renal outcomes associated with invasive versus conservative management of acute coronary syndrome:propensity matched cohort study[J].BMJ,2013,347:f4151.
[32]Lau JK,Anastasius MO,Hyun KK,et al.Evidence-based care in a population with chronic kidney disease and acute coronary syndrome[J].Am Heart J,2015,170(3):566-572.
[33]Klawansky S,Komaroff E,Cavanaugh PF Jr.,et al.Relationship between age,renal function and bone mineral density in the US population[J].Osteoporos Int,2003,14(7):570-576.
[34]Kidney Disease:Improving Global Outcomes(KDIGO)CKDWork Group.KDIGO 2017 clinical practice guideline update for the diagnosis,evaluation,prevention,and treatment of chronic kidney disease-mineral and bone disorder(CKD-MBD)[J].Kidney Int Suppl,2017,7:1-59.
[35]Nitta K,Yajima A,Tsuchiya K.Management of osteoporosis in chronic kidney disease[J].Intern Med,2017,56(24):3271-3276.
[36]St Peter WL,Guo H,Kabadi S,et al.Prevalence,treatment patterns,and healthcare resource utilization in medicare and commercially insured non-dialysis-dependent chronic kidney disease patients with and without anemia in the United States[J].BMC Nephrol,2018,19(1):67.
[37]Kidney Disease:Improving Global Outcomes(KDIGO)CKD Work Group.KDIGO clinical practice guideline for anemia in chronic kidney disease[J].Kidney Int Suppl,2012,2:283-335.
[38]Mikhail A,Brown C,Williams JA,et al.Renal association clinical practice guideline on anaemia of chronic kidney disease[J].BMC Nephrol,2017,18(1):345.
[39]Yaffe K,Ackerson L,Kurella Tamura M,et al.Chronic kidney disease and cognitive function in older adults:findings from the chronic renal insufficiency cohort cognitive study[J].J Am Geriatr Soc,2010,58(2):338-345.
[40]Chen YC,Weng SC,Liu JS,et al.Severe decline of estimated glomerular filtration rate associates with progressive cognitive deterioration in the elderly:a community-based cohort study[J].Sci Rep,2017,7:42690.
[41]Raphael KL,Wei G,Greene T,et al.Cognitive function and the risk of death in chronic kidney disease[J].Am J Nephrol,2012,35(1):49-57.
[42]Bronas UG,Puzantian H,Hannan M.Cognitive impairment in chronic kidney disease:vascular milieu and the potential therapeutic role of exercise[J].Biomed Res Int,2017,2017:2726369.
[43]Feng L,Yap KB,and Ng TP.Depressive symptoms in older adults with chronic kidney disease:mortality,quality of life outcomes,and correlates[J].Am J Geriatr Psychiatry,2013,21(6):570-579.
[44]Hedayati SS,Gregg LP,Carmody T,et al.Effect of sertraline on depressive symptoms in patients with chronic kidney disease without dialysis dependence:the CAST randomized clinical trial[J].JAMA,2017,318(19):1876-1890.
[2]Chudek J,Wieczorowska-Tobis K,Zejda J,et al.The prevalence of chronic kidney disease and its relation to socioeconomic conditions in an elderly Polish population:results from the national population-based study Pol Senior[J].Nephrol Dial Transplant,2014,29(5):1073-1082.
[3]Zhang L,Wang F,Wang L,et al.Prevalence of chronic kidney disease in China:a cross-sectional survey[J].Lancet,2012,379(9818):815-822.
[4]National Kidney Foundation.KDOQI clinical practice guideline for diabetes and CKD:2012 update[J].Am J Kidney Dis,2012,60(5):850-886.
[5]Kidney Disease:Improving Global Outcomes(KDIGO)CKDWork Group.KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease[J].Kidney Int Suppl,2013,3:1-150.
[6]上海慢性肾脏病早发现及规范化诊治与示范项目专家组.慢性肾脏病筛查诊断及防治指南[J].中国实用内科杂志,2017,37(1):28-34.
[7]Andrassy KM.Comments on'KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease'[J].Kidney Int,2013,84(3):622-623.
[8]Earley A,Miskulin D,Lamb EJ,et al.Estimating equations for glomerular filtration rate in the era of creatinine standardization:a systematic review[J].Ann Intern Med,2012,156(11):785-795.
[9]Schold JD,Navaneethan SD,Jolly SE,et al.Implications of the CKD-EPI GFR estimation equation in clinical practice[J].Clin J Am Soc Nephrol,2011,6(3):497-504.
[10]Benghanem Gharbi M,Elseviers M,Zamd M,et al.Chronic kidney disease,hypertension,diabetes,and obesity in the adult population of Morocco:how to avoid“over”-and“under”-diagnosis of CKD[J].Kidney Int,2016,89(6):1363-1371.
[11]Peralta CA,Katz R,Sarnak MJ,et al.Cystatin C identifies chronic kidney disease patients at higher risk for complications[J].J Am Soc Nephrol,2011,22(1):147-155.
[12]Brook MO,Bottomley MJ,Mevada C,et al.Repeat testing is essential when estimating chronic kidney disease prevalence and associated cardiovascular risk[J].QJM,2012,105(3):247-255.
[13]Arora P,Jalal K,Gupta A,et al.Progression of kidney disease in elderly stage 3 and 4 chronic kidney disease patients[J].Int Urol Nephrol,2017,49(6):1033-1040.
[14]Johansson L,Fouque D,Bellizzi V,et al.As we grow old:nutritional considerations for older patients on dialysis[J].Nephrol Dial Transplant,2017,32(7):1127-1136.
[15]Brunori G,Viola BF,Parrinello G,et al.Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly:a prospective randomized multicenter controlled study[J].Am JKidney Dis,2007,49(5):569-580.
[16]Windahl K,Faxen Irving G,Almquist T,et al.Prevalence and risk of protein-energy wasting assessed by subjective global assessment in older adults with advanced chronic kidney disease:results from the EQUAL study[J].J Ren Nutr,2018,28(3):165-174.
[17]Farrington K,Covic A,Nistor I,et al.Clinical practice guideline on management of older patients with chronic kidney disease stage 3b or higher(e GFR<45 m L/min/1.73 m2):a summary document from the European Renal Best Practice Group[J].Nephrol Dial Transplant,2017,32(1):9-16.
[18]Slinin Y,Guo H,Gilbertson DT,et al.Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis[J].Am J Kidney Dis,2011,58(4):583-590.
[19]Fischer MJ,O'Hare AM.Epidemiology of hypertension in the elderly with chronic kidney disease[J].Adv Chronic Kidney Dis,2010,17(4):329-340.
[20]James PA,Oparil S,Carter BL,et al.2014 evidence-based guideline for the management of high blood pressure in adults:report from the panel members appointed to the Eighth Joint National Committee(JNC 8)[J].JAMA,2014,311(5):507-520.
[21]Kidney Disease:Improving Global Outcomes(KDIGO)CKDWork Group.KDIGO clinical practice guideline for the management of blood pressure in chronic kidney disease[J].Kidney Int Suppl,2012,2:337-414.
[22]中国医师协会肾脏内科医师分会,中国中西医结合学会肾脏疾病专业委员会.中国肾性高血压管理指南2016[J].中华医学杂志,2017,97(20):1547-1555.
[23]Carey RM,Whelton PK,2017 ACC/AHA Hypertension Guideline Writing Committee.Prevention,detection,evaluation,and management of high blood pressure in adults:synopsis of the2017 American College of Cardiology/American Heart Association Hypertension Guideline[J].Ann Intern Med,2018,168(5):351-358.
[24]Ogurtsova K,da Rocha Fernandes JD,Huang Y,et al.IDFdiabetes atlas:global estimates for the prevalence of diabetes for2015 and 2040[J].Diabetes Res Clin Pract,2017,128:40-50.
[25]Robles NR,Felix FJ,Fernandez-Berges D,et al.Prevalence of abnormal urinary albumin excretion in elderly people:a Spanish survey[J].Int Urol Nephrol,2013,45(2):553-560.
[26]Russo GT,De Cosmo S,Viazzi F,et al.Diabetic kidney disease in the elderly:prevalence and clinical correlates[J].BMCGeriatr,2018,18(1):38.
[27]Bertoluci MC,Moreira RO,Faludi A,et al.Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes:a position statement from the Brazilian Diabetes Society(SBD),the Brazilian Cardiology Society(SBC)and the Brazilian Endocrinology and Metabolism Society(SBEM)[J].Diabetol Metab Syndr,2017,9:53.
[28]Lipska KJ,Krumholz H,Soones T,et al.Polypharmacy in the aging patient:a review of glycemic control in older adults with type 2 diabetes[J].JAMA,2016,315(10):1034-1045.
[29]Tonelli M,Wiebe N,James MT,et al.A population-based cohort study defines prognoses in severe chronic kidney disease[J].Kidney Int,2018,93(5):1217-1226.
[30]Thomas B,Matsushita K,Abate KH,et al.Global cardiovascular and renal outcomes of reduced GFR[J].J Am Soc Nephrol,2017,28(7):2167-2179.
[31]James MT,Tonelli M,Ghali WA,et al.Renal outcomes associated with invasive versus conservative management of acute coronary syndrome:propensity matched cohort study[J].BMJ,2013,347:f4151.
[32]Lau JK,Anastasius MO,Hyun KK,et al.Evidence-based care in a population with chronic kidney disease and acute coronary syndrome[J].Am Heart J,2015,170(3):566-572.
[33]Klawansky S,Komaroff E,Cavanaugh PF Jr.,et al.Relationship between age,renal function and bone mineral density in the US population[J].Osteoporos Int,2003,14(7):570-576.
[34]Kidney Disease:Improving Global Outcomes(KDIGO)CKDWork Group.KDIGO 2017 clinical practice guideline update for the diagnosis,evaluation,prevention,and treatment of chronic kidney disease-mineral and bone disorder(CKD-MBD)[J].Kidney Int Suppl,2017,7:1-59.
[35]Nitta K,Yajima A,Tsuchiya K.Management of osteoporosis in chronic kidney disease[J].Intern Med,2017,56(24):3271-3276.
[36]St Peter WL,Guo H,Kabadi S,et al.Prevalence,treatment patterns,and healthcare resource utilization in medicare and commercially insured non-dialysis-dependent chronic kidney disease patients with and without anemia in the United States[J].BMC Nephrol,2018,19(1):67.
[37]Kidney Disease:Improving Global Outcomes(KDIGO)CKD Work Group.KDIGO clinical practice guideline for anemia in chronic kidney disease[J].Kidney Int Suppl,2012,2:283-335.
[38]Mikhail A,Brown C,Williams JA,et al.Renal association clinical practice guideline on anaemia of chronic kidney disease[J].BMC Nephrol,2017,18(1):345.
[39]Yaffe K,Ackerson L,Kurella Tamura M,et al.Chronic kidney disease and cognitive function in older adults:findings from the chronic renal insufficiency cohort cognitive study[J].J Am Geriatr Soc,2010,58(2):338-345.
[40]Chen YC,Weng SC,Liu JS,et al.Severe decline of estimated glomerular filtration rate associates with progressive cognitive deterioration in the elderly:a community-based cohort study[J].Sci Rep,2017,7:42690.
[41]Raphael KL,Wei G,Greene T,et al.Cognitive function and the risk of death in chronic kidney disease[J].Am J Nephrol,2012,35(1):49-57.
[42]Bronas UG,Puzantian H,Hannan M.Cognitive impairment in chronic kidney disease:vascular milieu and the potential therapeutic role of exercise[J].Biomed Res Int,2017,2017:2726369.
[43]Feng L,Yap KB,and Ng TP.Depressive symptoms in older adults with chronic kidney disease:mortality,quality of life outcomes,and correlates[J].Am J Geriatr Psychiatry,2013,21(6):570-579.
[44]Hedayati SS,Gregg LP,Carmody T,et al.Effect of sertraline on depressive symptoms in patients with chronic kidney disease without dialysis dependence:the CAST randomized clinical trial[J].JAMA,2017,318(19):1876-1890.