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Aging seems to be the only available way to live a long life *** ,

The Mount Sinai Journal of Medicine vol. 70 no 1 Jan.2003

21%Medicare 2010 50+ 1900-2040

80/ 2030

Carlos Musso, Int Urol Nephrol 34:2002Geriatrics from the Beginning, Glosa 2001 - : -- -

Carlos Musso, Int Urol Nephrol 34:2002Geriatrics from the Beginning, Glosa 2001 - : -- -

- 1985: 1 1990: 1990: : Int J Urol Nephrol1994: 1 John Hartford Foundation 2000-2003: 2004: Geriatric CME credits

ACGME Accreditation Cancel for Graduate Medical Education

. . . Geriatric Nephrology be added to the core curriculum

. . . Fellows must have formal instruction clinical experience in disorders related to the aging kidney and unirary trait . . .

Renal ASN Week:2-day courses on Geriatric Nephrology 2008,2009,2010,2011Donald Kohan: Chair of the Commitee D.G. Oreopoulos: Co-Chair

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Wendy EHoy et al. Kidney International (2003) 63, S31S37

Wendy EHoy et al. Kidney International (2003) 63, S31S37

Elderly NeprhosclerosisRule AD, et al: Ann Int Med 152:2010n: 1203 Kidney Donors

Age GroupCrude Prevalence (95% Cl), %Crude Prevalence After Exclusion of Persons Who Received Therapy for Hypertension 18-29 y 2.7 2.7 %30-39 y 16 15 40-49 y 28 26 50-59 y 44 42 60-69 y 58 55 70-77 y 79 75 Overall 28 26

Characteristics Assoc with NephrosclerosisRule AD., et al: Ann Int Med 152:201024 hours urinary AE: P:0.010Nocturnal hypertension: P:0.019Hypertension P:0.002...a 32 mg increase in urinary albumin excretion,

a 21 mmHg increase in nocturnal diastole blood pressure,

a 32 mmHg increase in nocturnal systolic blood pressure and treated hypertension,

..has the same association with nephrosclerosis as an 8 year increase in age...

,

-E. M. Darmady et al. J. Path.-Vol. 109 (1973)

B. Kappel and S. Olsen , Virchows Arch. Path. Anat. Histol. 387, (1980)

Xin JZhou et al. Kidn Int (2008) 74, 710720

10%/ 40

0.87ml/min/year

Spitzer A : J Clin Invest 1974;53

(10-and 30-mo-old rats) Challah, M. et al. Am J Physiol Heart Circ Physiol 273:1997

Age and the Absolute GFR of males and Females Berg, U. B. Nephrol. Dial. Transplant. 2006 21:2577-2582

Barton, M. Nephrol. Dial. Transplant. 2005. 20

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1973 249 30-130ml/min

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COCKROFT-GAULT

1999 1628 5-90 ml/ min / 1.73m2

GFR = 186 x (.)-1.154 x () -0.203 x (0.742) if female x (1.210) if african american

MDRDLevey AS et al Ann Intern Med 130:461-470, 1999

7747 >65

Estimating renal function in older people: a comparison of three formulas Pedone C et al Age and aging 2006;35:121-126 CG, MDRD1, MDRD2 51.2ml/min 54.9ml/min 64.7ml/min ..

1 mg% GFR 120ml/min 20

eGFR Am J Kidn Dis,Vol 49,No 2,2007 GFR 60ml/min 80

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Pedone C et al Age and aging 2006;35:121-126 Epo Vi-D

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GFR:50ml/min

GFR

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- GFRLongitudinal Baltimore Study1958-1981Lindeman MD., et al: J Am Soc Geriat 1985. . . 254 GFRml, 0,75 /min/ 70% / . . . 30%

the decline in Renal function with age can be clinically insignificant unless other acute/chrome diseases that affect the RF are overlapped:arterial hypertensiondiabetes mellitus (II)CHF

Coresh J., et al: JAMA 298:2007Zhang L., et al: Am J Kidn Dis 51:2008 : 10% China 4% USA

Zhang Q., et al: MBC Public Health 8/2010 26 : USA, Europe, Asia

. . . >64 23.4%-35.8% GFR MDRD vs CCG

eGFR 40% 52% Tertiary Care Hospitals - 63.2 vs 59.3 300% e-GFR

35% e-GFRNoble E. Et al: Nephrol Dial Transpl 23/2010Richards N., et al: Nephrol Dial Transpl 24/2011

GFR ;13,1% 5% 1 27,7% 30,4% 4 5 GFR 60

Kidney International (2007) 72, 632637 60 GFR

Nephrol Dial Transplant (2010) 25: 28322836

Nephrol Dial Transplant (2010) 25: 28322836 ; combine all levels of eGFR with ACR measurements..

o Cores et al, JAMA,2011 . . . GFR 60-89 ml/min

. . .

. . . 75% >70 GFR

GFR Levey AS et al Kidney Int 2005;67:2089-00 2005 GFR..

Marker of Kidney DamageGFRCKDWhat to do?+60YAction Plan-60N

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J Am Soc Nephrol 17: 846853, 2006 eGFR

Chart8

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Stage 3 CKD

Stage 4 CKD

Stage 5 CKD

Sheet1

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Hypertension0.2

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Outflow obstruction0.1

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All cardiovascular disease0.2190.7430.8390.894

Diabetes0.0770.1490.2560.191

Ischaemic heart disease0.0490.2650.3180.234

Heart failure0.0040.0850.1750.085

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Hypertension0.1320.5540.6450.809

Sheet2

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End- StageProgressionInitiationAt Risk , , ( GFR) , Sarnak and Levey, Am J Kidney Dis 2000;35:S11731. ,

Seminars in Dialysis 23: 129133, 2010

http://www.cdc.gov/diabetes/pubs/estimatesNational Diabetes Fact Sheet 2011 27% > 65

9, NPHS1, HSPG2, SELL, CNDP1, LAMNA, ELMO1ACE, ANP, AGTAKR1B1, GFPT2, SLC2A1, GECCR5, IL1, IL6, IL1RN, TGFBR, RANTESAPOENOS3, ENPP1, MnSODPPARG, TSC22, PRKCB, BDKRB2P22phox, SLC12A3

The Am J Med 1985 May;78(5):785-94. 20-25 30%-40%

, , Endocrine Reviews 25:9711010, 2004

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Nephrol Dial Transplant (2009) 24: 12121219 Japan Diabetes Clinical Data Management study (JDDM15)

, : 1 10 Am J of Kidn Dis, Vol 49, No 2, Suppl 2 (Febr), 2007

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Diabetes Care 32:14971502, 200955% 2 3

Diabetes,52,2003 Type I Diabetes Melitus

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: GFR > 30% GFR 2-3 RASAmerican Journal of Kidney Diseases, 49, 2, Suppl 2 (February), 2007

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Skyller JS.,et al .Diabetes Care, 32,1 2009Intensive Glycemic Control and the Prevention of Cardiovascular Events:Implications of the ACCORD, ADVANCE, and VA Diabetes Trials

A position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart AssociationADA, C-level recommendation; ACC/AHA, level of evidence C

Perhaps we should call for future guidelines to be formulated in such a way that they would set various treatment targets and regimens for various groups of patients, depending on the stage of the disease they are at

for newly diagnosed and uncomplicated ones an HbA1c of

End- StageProgressionInitiationAt Risk , , ( GFR), , Sarnak and Levey, Am J Kidney Dis 2000;35:S11731. ,

ESH/ESC Guidelines J Hypertension 2007; 25:11051187

(%) - NHANES III Franklin SS, Jacobs M, Wong ND, et al. JACC. 2000; 35: 334A020406080100 ()8070-79

, K K 61

958.074 Lancet 2002;360:1903-1913

, 140 90 mmHg??? ?????

< 140 mmHg @ < 120 mmHg34% (n = 1.617) > 65

N Engl J Med 2010; 362: 1575-1585 ACCORDthe intensive-therapy group had significantly higher rates of serious adverse events.. ,, .

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331 857 (60%) 2 Hypertension. 2007;50:172-180 , < 70 mmHg

Arch Intern Med. 1999;159:273-280792 76 O Y H A A K

< 150 mmHg;

160 mmHg < 150/80 mmHgN Engl J Med 2008;358:1887-98perindoprilindapamide : HYVET Study

: HYVET3845 > 80 >160 mmHg : ( ) placebo 1,8 N Engl J Med 2008; 358: 1887-1898 7 %

Journal of Hypertension 2009, 27:21212158

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, RAS?????

American Journal of Kidney Diseases, Vol 49, No 2, Suppl 2 (February), 2007

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Nephrol Dial Transplant (2010) 25: 39773982 RAS

Physicians should remember that the most common cause of end-stage renal disease among elderly persons with preexisting CKD is acute kidney injury secondary to radiocontrast procedures, anti-inflammatory drugs, or worsening heart failure, not a gradual decrease consistent with the natural history of CKD itself. Use of RAS blockers in such patients puts them at increased risk for worsening CKD.Sarafidis PA & Bakris GL, Ann Intern Med 2009

Start low, go slowbut get there

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/ Ferrario CG: Geropharmacology: AACN Adv Crit Care 19:134149, 2008Ferrario CG: Geropharmacology: AACN Adv Crit Care 19: 2335, 2008

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The issue in treating elderly patients with kidney disease is not efficacy but safetyGolden Rule

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