ASN: Geriatric Nephrology Videos

ASN launched a new five-part video series, "Improving Dialysis Rounds for Geriatric Patients," produced by the ASN Geriatric Nephrology Advisory Group and made possible with support from the Association of Specialty Professors. The publicly available, free video series, accessible online and, covers important aspects of care of aging patients, including assessment, treatment decisions for patients with advanced kidney disease, care of elderly patients receiving chronic dialysis, recognition of physical and mental decline, the importance of quality of life, and of shared decision-making between patients, caregivers, and providers.

Have a look at this great educational resource.

Geriatric Workforce Shortage: What can we learn?

Recently articles in the medical literature shed light on an important shortage besides nephrology- geriatricians. Geriatric medicine was founded as a specialty in 1988 and a fellowship track was created. With the baby boomers growing older and human lifespan expanding, multiple medical problems, geriatric medicine is an important field of medicine that should attract many applicants. But just like Nephrology, there is a major workforce shortage the geriatricians are facing today in the United States. Why is that and can this field survive?

Apparently, just like Nephrology, geriatric medicine is an unpopular career choice for medical students and residents due to perceived low prestige, low salaries and complicated patients.  Nephrology has many older patients, not very high salaries and similarly complicated patients to take care of.  American Society of Nephrology has created a committee on the Workforce shortage and ways to come up with ideas on how to increase interest in Nephrology. You can watch a recent video clip from ASN regarding this.

The article in annals proposes potential solutions on how to increase interest in geriatrics and improve geriatrics care. Perhaps Nephrology can learn from them

The suggestions are:

1********Geriatric focus models (ACOs) might help relieve some of that frustration. A similar proposal has been made in Nephrology.

2*********  “Gerontologize” teaching incentives. If the residents and medical students are not taking geriatrics as careers and fellowships are vacant, then perhaps energy should be redirected in geriatric educational resources towards teaching non geriatricians to be better geriatricians.   Nephrology is part and parcel of UGE and GME- unclear if this strategy will work in our field.  Will there ever be a point in time when general internists might have to do some basic nephrology care given lack of experts in the field.  In parts of the world, pediatric nephrologists are only found in academic centers, and initial treatments of many diseases including nephrotic syndrome is initiated by general pediatricians. 

3******** Train non geriatricians in geriatric medicine to deliver this education to the UGE and GME.  It appears that the field of geriatrics is not really focusing on how to increase interest but to shift gears and allow others to take charge and teach and practice geriatrics as part of their general medical practice. Given there is technical issues with dialysis and immunosuppresion management in transplantation, would a general internist be comfortable? Hard to see this happen in Nephrology

“It appears that if there is no increase in compensation, or professional recognition, the field of geriatric medicine is in for extinction.” – The article states. Should society needs and demands  be considered when making career choices? The society is going to need geriatricians and nephrologists, there is going to be a major shortage. Students in medicine and residents in medicine, should try to consider these fields of choices as they will be fulfilling a major need for the society as well.  

Ref: http://www.annals.org/content/156/9/654.full

eAJKD: Advanced age and Kidney Transplantation

Geriatric nephrology is on the rise as the baby boomers age, and more and more patients will encounter nephrologists. Transplant nephrology is facing this challenge as well. Check out the two part interview series in eAJKD with the author of a recent article on transplantation outcomes in the elderly.


Interview Part 1
Interview Part 2

IMMUNOSUPPRESSION IN THE ELDERLY: WHATS THE BEST INDUCTION AGENT???

The incidence of elderly patients with ESRD is increasing, as is the number of elderly listed for kidney transplantation. In fact, we are transplanting more and more elderly patients over the age of 70. Studies suggest that the elderly have excellent graft survival, possibly due to a less robust immune response, but unfortunately still have a higher mortality than younger patients. This dichotomy led me to wonder what the best immunosuppression is for the elderly. Logic would suggest they need less intense induction immunosuppression to avoid infectious complications. At the same time however, perhaps more intense induction can reduce the incidence of rejection and allow reduced maintenance immunosuppression (such as steroid free or low CNI) improving both infectious and cardiac outcomes. Reviewing the literature led me to 3 interesting papers on induction immunosuppression and outcome in the elderly.

Two studies were registry analysis^1,2 and one was a single center study³. The registry analysis compared 3 agents: IL-2 inhibitors (anti-CD25), antilymphocyte globulin (thymoglobulin), and alemtuzumab. They suggested worse outcome with alemtuzumab compared to thymoglobulin or anti-CD25. Although outcomes with thymoglobulin and anti-CD25 were similar, thymoglobulin had a lower incidence of rejection and surprisingly revealed a trend to better patient survival! This was especially prevalent in high risk recipients whom also enjoyed better graft survival. It is possible that this effect is due to less maintenance immunosuppression and less requirement for high doses of immunosuppression to treat rejection. The single center study evaluated different cumulative doses of Thymoglobulin and outcome within different age groups. What they found was elderly (age > 60) patients had a reduced survival if they received > 6mg/kg of Thymoglobulin.

Looks like low dose thymo induction wins again!

References:

1. Clin J Am Soc Nephrol 2011;6: 1168-1178 PMID:21511836

2. Am J Nephrol 2011; 34:534-541 PMID:22104284

3. Clin Transplant 2011;25:E250-E256 PMID:21231963

CLINICAL CASE 36, ANSWERS AND SUMMARY

Which of the following regarding Anti GBM disease in elderly is true?

This entity is non existent in the age> 65   0%
Anti GBM disease in the elderly is more of a female predominance 15% 
Anti GBM disease in the elderly is more severe than in the younger patients 17%
Anti GBM disease has more severe lung hemorrhage than younger patients 10%
Anti GBM disease has a significantly higher proportion of positive ANCA results in this age group 57%

Good work all. Majority got this one right. Recently in AJKD this topic was reviewed looking especially at cases in the elderly.  This entity does exist in the elderly and fairly common. It has more of a male predominance and it is actually LESS severe than when it happens in younger patients.  The lung disease is also LESS severe. The correct answer hence is the last one- it does occur a lot of time concurrently with a positive ANCA blood test in this age group. This group also has lower proteinuria at presentation and higher GFR on presentation. 

Ref:

http://www.ncbi.nlm.nih.gov/pubmed/21421136
http://www.ncbi.nlm.nih.gov/pubmed/21168945

Geriatric Nephrology

The Feb 2011 issue of ASN Kidney News highlights an important subset of Nephrology- Geriatric Nephrology.
A series of articles are mentioned from ESRD, Transplantation and educational opportunities in this field.
There is a society called the International Society of Geriatric Nephrology that was formed few years ago.
A Journal called Geriatric Nephrology and Urology also exists that caters to articles and studies to this important field in Nephrology.
A nephsap in Jan/Feb 2011 is going to be focused on Geriatric Nephrology as well.
Topics that are included are biology of aging and the kidney, GFR and age, glomerular diseases, geriatric hypertension, Pallative care options are a few topics.
Have a look at this months' very important issue focused on a specific theme
http://onlinedigeditions.com/publication/?m=15191&l=1