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Older adults with advanced chronic kidney disease (CKD) have a high burden of geriatric syndromes (GS). A geriatric assessment is fundamental to optimize care, implement interventions, and guide shared decision-making. In 2022 the first integrated Geriatric Nephrology Clinic (GNC) in Mexico was opened at our Institution. We aimed to describe GS in older patients with CKD, and their association with decision-making.
We included patients referred to the GNC between 01/2022 and 10/2023. Patients ≥70 years with eGFR ≤20 mL/min are referred for geriatric assessment and follow up by a team composed of a nephrologist and a geriatrician in a single visit. Assessments and prognostic tools are then discussed with patients and caregivers to reach shared decision-making. Medical record data for geriatric assessment and GS was analyzed using descriptive statistics. Decision-making regarding dialysis initiation (RRT) or comprehensive conservative management (CCM), and its association with GS, was documented. The patients’ status regarding RRT vs. CCM was reviewed every 3 months.
107 pts were included: 86 had non-dialysis dependent (NDD) CKD and 21 were on RRT (HD = 14, PD = 7). Three-monthly follow up data was available for 91 patients. Mean age was 80±7 years, 49% were female, 43% had low-income, and 41% had diabetes as the cause of CKD. The Charlson Comorbidity Index (CCI) was high (≥8) in 53%. RRT patients were younger (77.2±7.6 vs. 81.1±6.7, p<0.05), had lower CCI (6.9±1.9 vs. 7.9±2.1, p<0.05), were more likely to have healthcare coverage (71% vs. 44%, p = 0.02), and less likely to have diabetes (29% vs 44%) and low physical performance (36% vs. 73%, p<0.05). Median dialysis vintage was 3 years (IQR 1.8, 6.0). NDD patients had a mean eGFR of 14.6±5.9 mL/min, and 81% had ≥A2 albuminuria. Risk of progression to ESKD was high (2-year KFRE >40%) in 29%. The most common GS were polypharmacy (94%), disability in instrumental activities of daily living (IADLs) (91%), and frailty (77%). Figure 1 describes GS prevalence according to the baseline treatment status.
After the first visit, 51/86 (59%) NDD patients were considered suitable RRT candidates. Of those, 21% opted for RRT, 63% chose CCM or were undecided, and 16% remained in pre-dialysis status. More than half of patients (56%) who chose CCM lacked healthcare coverage, although only 3 patients (9%) highlighted financial issues as a reason to not pursue RRT. During follow up, 3 patients started RRT (2 HD, 1 PD), 14 patients died (1 PD withdrawal, 1 after HD start, 12 on CCM) and 10 were lost to follow up.
The implementation of our multidisciplinary GNC has led to the identification of GS among older patients with CKD and to a more structured approach to shared decision-making regarding treatment and follow-up. We found a high prevalence of GS and comorbidity among our patients. Future research plans include the implementation of geriatric-assessment guided interventions aimed at improving the outcomes of older adults with CKD.