Advances in Chronic Kidney Disease RSS feed: Current Issue. The purpose of Advances Chronic Kidney Disease is to provide in-depth, scholarly review articles about the care and management of persons with early kidney disease and kidney failure, as well as those at risk for kidney disease. Emphasis is on articles related to the early identification of kidney disease; prevention or delay in progression of kidney disease; the multidisciplinary case management of patients with chronic kidney disease or kidney failure, organ effects of kidney disease; epidemiology and outcomes research in chronic kidney disease; benefits and complications of the primary treatment methods, dialysis and transplantation; technical aspects of the delivery of uremia therapy; care of the critically ill patient with kidney failure in the intensive care setting; new therapies for kidney failure; and health care research in chronic kidney disease. The full spectrum of basic science through clinical care is covered in these reviews. Clinical care issues stress the multidisciplinary team approach to the care of kidney patients. Topics covered will be of interest to practicing nephrologists (pediatric and adult), nephrology fellows (pediatric and adult), nurses, technicians, dietitians, and social workers caring for patients with kidney disease. Each bimonthly issue of Advances in Chronic Kidney Disease presents focused review articles devoted to a single topic of current importance in clinical nephrology and related fields. 2010 Issues, Vol. 17 January HIV and Kidney Disease James Novak, MD, PhD, Lynda Szczech, MD, MSCE March Autosomal Dominant Polycystic Kidney Disease (ADPKD) Terry Watnick, MD, York Pei, MD, MSc May CKD: Public Health Perspectives Rajiv Saran, MD, MS, Vahakn Shahinian, MD, MS July Aging and Chronic Kidney Disease Mark Unruh, MD, MSc, Linda Fried, MD, MPH September Optimizing Pharmacotherapy in Chronic Kidney Disease Carol Moore, PharmD, Amy Barton Pai, Pharm D, BCPS November Proteomics Jon Klein, MD, John Arthur, MDhttp://www.ackdjournal.org/?rss=yesElsevier Inc.en © 2010 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved. Advances in Chronic Kidney Disease1548-5595174July 2010 © 2010 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved. healthpermissions@elsevier.comhttp://www.ackdjournal.org/article/PIIS1548559510000819/abstract?rss=yesDo today's super centenarians have different kidneys than the rest of the population? Maybe, maybe not. If their GFRs declined in accordance with the 4-variable Modification of Diet in Renal Diseases equation or the average annual decline predicted by the Baltimore Longitudinal Study of Aging, most would still retain sufficient residual renal function to sidestep the need for renal replacement therapy. However, in the Ovidian sense, “change” is the only absolute in life, and so the kidney function of these long-living individuals must have changed, biologically and physiologically, but to what extent?Men Grow Old, Pearls Grow Yellow…Jerry Yee10.1053/j.ackd.2010.05.004Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Editorial289290http://www.ackdjournal.org/article/PIIS1548559510000820/abstract?rss=yesIn the 1970s, the Baltimore Longitudinal Study of Aging (BLSA) was a longitudinal study of healthy adults with a goal to understand the changes that occur with age. Kidney function was assessed by creatinine clearance collected in a general clinical research center and individuals were examined every 12 to 18 months. With an increase in age, there was a decline in clearance, with little change in serum creatinine. The latter was because of a decrease in creatinine generation that was in turn caused by a decrease in muscle mass with age. Although individuals with treated hypertension were excluded from the studies of kidney function, BLSA did not exclude all hypertensives. Subsequent analyses reported an age-related decline when those with a mean arterial pressure >107 were excluded, but this would include individuals with isolated systolic hypertension (eg, a person with a blood pressure of 160/80). As isolated systolic hypertension occurs more commonly with an increase in age, it is most likely that many of the older individuals included in the study would be considered hypertensive, if the study were repeated today.Aging in Kidney Disease: Key Issues and Gaps in KnowledgeLinda F. Fried, Mark L. Unruh10.1053/j.ackd.2010.05.005Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Guest Editorial291292http://www.ackdjournal.org/article/PIIS1548559510000534/abstract?rss=yesThe world's population is aging, with the number of older adults projected to increase dramatically over the next 2 decades. This trend poses major challenges to health care systems, reflecting the greater health care use and more comorbid conditions among elderly adults. Chronic kidney disease (CKD) is a substantial concern in the elderly population, with both an increasing incidence of treated kidney failure with dialysis as well as a high prevalence of earlier stages of CKD. Given the high burden of risk factors for CKD, the high prevalence of CKD in the elderly population is not surprising, with the rise in obesity, diabetes, and hypertension in middle-aged adults likely foreshadowing further increases in CKD prevalence among the elderly population. It is now commonly agreed that the presence of CKD identifies a higher risk state in the elderly population, with increased risk for multiple adverse outcomes, including kidney failure, cardiovascular disease, cognitive impairment, and death. Accordingly, CKD in older adults is worthy of attention by both health care providers and patients, with the presence of a reduced glomerular filtration rate or albuminuria in the elderly potentially informing therapeutic and diagnostic decisions for these individuals.Chronic Kidney Disease and End-Stage Renal Disease in the Elderly Population: Current Prevalence, Future Projections, and Clinical SignificanceLesley A. Stevens, Gautham Viswanathan, Daniel E. Weiner10.1053/j.ackd.2010.03.010Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles293301http://www.ackdjournal.org/article/PIIS1548559510000790/abstract?rss=yesAge-associated loss of kidney function has been recognized for decades. With aging, many subjects exhibit progressive decreases in glomerular filtration rate and renal blood flow, with wide variability among individuals. The fall in glomerular filtration rate is because of reductions in the glomerular capillary plasma flow rate and the glomerular capillary ultrafiltration coefficient. In addition, a primary reduction in afferent arteriolar resistance is associated with an increase in glomerular capillary hydraulic pressure. These hemodynamic changes occur in concert with structural changes, including loss of renal mass; hyalinization of afferent arterioles and in some cases, development of aglomerular arterioles; an increase in the percentage of sclerotic glomeruli; and tubulointerstitial fibrosis. Aging is associated with altered activity and responsiveness to vasoactive stimuli, such that responses to vasoconstrictor stimuli are enhanced, whereas vasodilatory responses are impaired. Changes in the activity of the renin–angiotensin and nitric oxide systems appear to be particularly important, as is the modulating effect of gender. These changes may predispose the older kidney to acute kidney injury, including normotensive ischemic nephropathy, as well as progressive chronic kidney disease.The Aging Kidney: Physiological ChangesJessica R. Weinstein, Sharon Anderson10.1053/j.ackd.2010.05.002Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles302307http://www.ackdjournal.org/article/PIIS1548559510000510/abstract?rss=yesThe 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.Electrolytes in the AgingLynn E. Schlanger, James L. Bailey, Jeff M. Sands10.1053/j.ackd.2010.03.008Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles308319http://www.ackdjournal.org/article/PIIS1548559510000480/abstract?rss=yesOlder US adults bear a substantial burden of chronic disease and take an average of five prescription and non-prescription medications per day. Recent data suggest that over 20% of older adults have chronic kidney disease (CKD) as defined by an impaired glomerular filtration rate. These individuals often have multiple comorbidities, including diabetes, hypertension, and cardiovascular disease. Although patients with CKD may receive substantial benefits from prescribed medications, they are also at high risk for adverse drug events and polypharmacy. In this review, we outline the risks and benefits of medication use in the CKD population as a specific case within geriatric pharmacoepidemiology as a framework.Medication Issues in Older Individuals With CKDDena E. Rifkin, Wolfgang C. Winkelmayer10.1053/j.ackd.2010.03.005Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles320328http://www.ackdjournal.org/article/PIIS1548559510000807/abstract?rss=yesAs the population of the United States ages, the prevalence of age-related chronic conditions such as hypertension and chronic kidney disease (CKD) will also increase. Available studies in nationally representative samples and select outpatient populations indicate that hypertension is very common in older adults with CKD, and despite the use of medication it is often poorly controlled. Generally, less than one-third of the elderly patients with CKD achieve a level of blood pressure control consistent with that of the current guideline recommendations. However, limited evidence is available from observational studies and clinical trials to inform management of hypertension in the elderly population with CKD. The available published data suggest that the relationship between clinical outcomes and the treatment of hypertension among older adults with CKD is complex and distinct from that of their younger counterparts. Larger and more robust analyses are needed for a better understanding of the association between hypertension, its treatment, and clinical events in elderly patients with CKD.Epidemiology of Hypertension in the Elderly With Chronic Kidney DiseaseMichael J. Fischer, Ann M. O'Hare10.1053/j.ackd.2010.05.003Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles329340http://www.ackdjournal.org/article/PIIS1548559510000753/abstract?rss=yesAlthough age-related alterations in the structure and function of the kidney may be inevitable, up to one-third of the older population shows no age-related decline in kidney function. As measured by inulin clearance, the healthy elderly population will be able to maintain a normal, albeit lower than their younger counterparts, glomerular filtration rate. This age-related decline in glomerular filtration rate will remain clinically insignificant in the absence of acute or chronic conditions adversely affecting kidney function or reserve. The contribution of illnesses associated with aging, such as hypertension (HTN) and diabetes mellitus, may accelerate this decline in kidney function with aging and therefore increase the incidence of chronic kidney disease. With the predicted global increase in the elderly population, the effect on health care costs and on society in general will be enormous. This will require intensive efforts at controlling diseases, such as HTN, along with continued efforts at promoting increased aerobic exercise, and a low sodium, low fat diet. The age-related decline in kidney function will, in turn, affect not only the choice of therapeutic agent in the treatment of HTN but the dosing and need for combination therapy as well. Although these approaches will need to be as aggressive as possible, they will also need to be balanced with the individual patient's potential for adverse outcomes such as orthostatic hypotension, worsening kidney function, and hyperkalemia (depending upon the agent chosen).Hypertension and Chronic Kidney Disease in the ElderlyPhilip A. Kithas, Mark A. Supiano10.1053/j.ackd.2010.04.003Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles341347http://www.ackdjournal.org/article/PIIS154855951000039X/abstract?rss=yesPoor physical functioning in dialysis patients has been well documented. Several studies have reported an association of poor kidney function with adverse physical functioning outcomes, even in elderly persons with mild decrements in kidney function. These associations have been observed across multiple domains of physical function. This review summarizes the current research on physical functioning in kidney disease, with a special focus on elderly populations. Elderly persons with kidney disease may especially be at a high risk for disability and other adverse outcomes because of the dual effects of aging and kidney dysfunction on physical functioning. Both the correction of anemia and physical activity are effective for at least moderate improvements in physical function although these studies have been conducted primarily in younger persons with less comorbidity. The evidence that exists on exercise interventions in older adults with kidney disease is promising, although this population has been underrepresented in trials to date. More research on potential interventions to prevent or reduce poor physical functioning is needed in elderly persons with kidney disease.Physical Functioning in Elderly Persons With Kidney DiseaseMichelle C. Odden10.1053/j.ackd.2010.02.002Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles348357http://www.ackdjournal.org/article/PIIS1548559510000881/abstract?rss=yesThe demographic factor over age 65 years represents the fastest growing segment of the end-stage kidney disease, wait-listed for kidney transplant, and transplanted populations. As a result, transplant physicians are increasingly asked to evaluate candidacy in older patients. Relatively little attention has been paid to the unique aspects of the pretransplant evaluation in older persons. The natural tendency is to focus on individual comorbidities as isolated entities, such as a history of coronary heart disease, while ignoring factors more specific to the aging process itself. Assessment of the burden of comorbidity along with the application of standardized geriatric assessment tools, such as the measurement of physical and cognitive function, has the potential to refine the pretransplant evaluation process in older kidney transplant candidates.The Evolving Challenge of Evaluating Older Renal Transplant CandidatesErica L. Hartmann, Christine Wu10.1053/j.ackd.2010.03.012Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles358367http://www.ackdjournal.org/article/PIIS1548559510000479/abstract?rss=yesChronic kidney disease (CKD) has increasingly become a “geriatric” disease, with a dramatic rise in incidence in the aging population. Patients aged >75 years have become the fastest growing population initiating dialysis. These patients have increased comorbid diseases and functional limitations which affect mortality and quality of life. This review describes the challenges of dialysis initiation and considerations for management of the elderly subpopulation. There is a need for an integrative approach to care, which addresses management issues, health-related quality of life, and timely discussion of goals of care and end-of-life issues. This comprehensive approach to patient care involves the integration of nephrology, geriatric, and palliative medicine practices.An Integrative Approach to Advanced Kidney Disease in the ElderlyJane O. Schell, Michael J. Germain, Fred O. Finkelstein, James A. Tulsky, Lewis M. Cohen10.1053/j.ackd.2010.03.004Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Articles368377http://www.ackdjournal.org/article/PIIS1548559510000674/abstract?rss=yesWith the increasing prevalence of hypertension, there has been a growing interest in understanding the health-related quality of life (HRQOL) of patients with hypertension. Although hypertension is often perceived as asymptomatic, it is associated with impaired HRQOL because of complications or comorbidities, awareness of the diagnosis, and adverse effects from antihypertensive medications. This article focuses on the literature published since 2000, on HRQOL in elderly hypertensive individuals as well as hypertensives with co-existent diseases, including chronic kidney disease, cardiovascular disease, and diabetes mellitus. Most of the studies found that hypertensive individuals with co-existent co-morbidities tend to have lower HRQOL than those with hypertension alone, and identified the number of co-morbid illnesses as an independent determinant of HRQOL. The most pronounced effect was noted in the physical function domains of HRQOL. Studies have also examined the effects on HRQOL of specific classes of antihypertensive drugs without specific demonstration of superiority of one drug class over another in terms of HRQOL measures. Although there is evidence in favor of angiotensin-converting enzyme–inhibition for improving renal and cardiovascular outcomes in hypertensive patients, its role in ameliorating HRQOL outcomes remains to be established.Health-Related Quality of Life in Hypertension, Chronic Kidney Disease, and Coexistent Chronic Health ConditionsRitu K. Soni, Anna C. Porter, James P. Lash, Mark L. Unruh10.1053/j.ackd.2010.04.002Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Online Exclusivese17e26http://www.ackdjournal.org/article/PIIS1548559510000765/abstract?rss=yesNocturia is a frequently encountered problem in clinical practice and a reason for nephrology consultation. Many studies have clearly shown the negative effect of nocturia on several aspects of health-related quality of life and morbidity. Age-associated physiological, structural, hormonal, and histological changes play an important role in the increasing incidence of nocturia in elderly individuals. Besides urologic conditions, nocturia may also be the initial presenting symptom in chronic kidney disease, as well as other systemic diseases. Therefore, it is essential to understand the complex pathophysiology among these factors to establish a precise diagnosis and appropriate management strategies. This review will provide an overview of the effect of aging on the kidneys and urinary system, the pathophysiology, clinical assessment, and treatment strategies of nocturia, and its effect on health-related quality of life.Nocturia and Aging: Diagnosis and TreatmentSarinya Boongird, Nirav Shah, Thomas D. Nolin, Mark L. Unruh10.1053/j.ackd.2010.04.004Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Online Exclusivese27e40http://www.ackdjournal.org/article/PIIS1548559510000789/abstract?rss=yesBone disease can lead to significant morbidity and mortality for those who are afflicted by it, irrespective of etiology. Two very prevalent causes of bone disease that contribute to this are osteoporosis and chronic kidney disease (CKD). The modern era has seen important advances in the understanding and management of these processes, but in elderly patients with CKD it remains a complex issue that has yet to be clearly defined. Changes in mineral metabolism that accompany the loss of renal function result in a spectrum of bone disease that occurs concomitantly with bone loss secondary to aging. As such, the traditional paradigms used to manage bone disease may not be appropriate for these patients. With the aging dialysis population, a better understanding of these 2 processes and their interplay deserves more attention.Bone Disease in Elderly Individuals With CKDSheru Kansal, Linda Fried10.1053/j.ackd.2010.05.001Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0Online Exclusivese41e51http://www.ackdjournal.org/article/PIIS154855951000100X/abstract?rss=yesMasthead10.1053/S1548-5595(10)00100-XAdvances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0FrontmatterA2A2http://www.ackdjournal.org/article/PIIS1548559510001011/abstract?rss=yesEditorial Board10.1053/S1548-5595(10)00101-1Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0FrontmatterA3A3http://www.ackdjournal.org/article/PIIS1548559510001023/abstract?rss=yesTable of Contents10.1053/S1548-5595(10)00102-3Advances in Chronic Kidney Disease 17, 4 (2010)2010-07-01Advances in Chronic Kidney Disease2010-07-01174S1548-5595(10)X0004-0FrontmatterA5A6