Geriatric Care To Deal With Chronic Kidney Disease And Diabetic Nephropathy In Ageing Population

Diabetes mellitus is a major cause of chronic kidney disease and end-stage renal disease worldwide, and this is true even in our country.

CKD and Diabetic Nephropathy in the ageing population

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Diabetes mellitus and hypertension still remain the major illnesses that cause CKD in the elderly, but diseases like obstructive diseases of the kidneys and outflow tract and malignancy also need to be evaluated for. Diabetes mellitus is a major cause of chronic kidney disease and end-stage renal disease worldwide, and this is true even in our country. It generally occurs in individuals with long-standing and uncontrolled diabetes for about 15 to 20 years. 

In this regard, Dr. G K Prakash, who is a Senior Consultant Nephrologist, at Manipal Hospital, Malleshwaram, Bangalore said, "The incidence of diabetes increases with advancing age, and some ways to diagnose diabetic kidney disease include checking for protein in urine and assessing kidney function. Symptoms may include swelling and proteinuria (protein in the urine)."

"Further, abnormal kidney function can be indicated by elevated creatinine levels in blood tests. Though the risk of diabetic kidney disease increases with age, its development is closely dependent on when it is detected. Earlier, people with diabetes for 15-20 years were considered susceptible to kidney disease. Nowadays, people often detect their diabetes very late, which means they may already have kidney issues related to their diabetes," he added.

He then listed down two things that are to be kept in mind:

• Firstly, it is very important for one in the elderly group to screen for baseline kidney functions along with other routine parameters once a year, at least as GFR starts falling with age, approximately 10% for every decade after the age of 35-40. These individuals, especially the geriatric group, are prone to renal injury with any minor insults (like dehydration, infections, Nephrotoxic drugs in the form of pain killers, antibiotics, alternative forms of medicine, etc.). A serum creatinine of 1 mg/dl in a 40-year-old individual may have normal GFR, but an elderly person of 80 years with the same creatinine of 1 mg, would have abnormal GFR (lower kidney function) because of senescent kidneys.
• Another point to note is that the medications and the type of medications also need to be modified as their metabolism is a little different from a younger individual. One also needs to keep track of any of the pre-existing chronic ailments like diabetes mellitus, hypertension, cardiovascular diseases, Chronic respiratory diseases in the form of COPD (Chronic Obstructive Pulmonary Disease), etc., as dosing and group of drugs that can be safely used are going to be slightly different.

Kidney Disease In Elderly Population:

Dr. Garima Aggarwal who is a Consultant Nephrologist and Renal Transplant Physician, at Manipal Hospital, Varthur, Bangalore said, "Another aspect of kidney care that has to be emphasized in elderly patients is the choice of treatment for kidney failure or end stage kidney disease. End stage kidney disease refers to a stage of complete loss of kidney function when a person requires either dialysis or kidney transplantation for survival. Although dialysis does improve survival compared to medical management in CKD patients, this benefit is largely diminished in older patients and those already having other health conditions. Data suggests that quality of life also remains the same in older patients whether on dialysis or not. This stresses upon the need for patient centered approach and shared decision making between the various caregivers of elderly patients with kidney diseases, rather than focusing purely on disease specific medical advancements."

Geriatric Care Plan For CKD (Chronic Kidney disease)

Dr. Garima Aggarwal said, "Geriatric care refers to the comprehensive healthcare and wellness services provided to elderly individuals. Geriatric care is particularly relevant in the context of CKD as elderly suffering from kidney diseases are more prone to poor kidney outcomes, high risk of heart disease, high risk of stroke, multiple drug prescriptions, poor mental health, loss of mobility and function, cognitive decline, financial and social burden of CKD treatments, along with the other unique challenges of aging."

A geriatric care plan for CKD patients consists of a multidisciplinary approach, involving

• Geriatricians or primary care doctors focussing on multiple prescriptions, and coordinating care with different specialists
• Nephrologists for treatment and management of complications of CKD
• Counsellors for mental health related issues, motivation, discuss goals of care, educate about the disease and set expectations
• Nutritionists
• Physical therapists
• Palliative care doctors for management of pain and other discomforts
• Social workers to help navigate the cost and burden of dialysis and other treatments

The Awareness Required:

Dr. Jatin Kothari, who is the Director of Nanavati Max Institute of Renal Sciences & Transplant, Nanavati Max Super Speciality Hospital, Mumbai said, "The prevalence of chronic kidney disease (CKD) and diabetic nephropathy is mounting steadily among global elderly populations in recent years. Diabetic nephropathy, a dire complication of diabetes, signifies kidney damage caused by chronic high blood sugar levels. If not detected and managed in time, it can advance to CKD—a progressive deterioration in kidney function. This decline impacts the kidneys' ability to filter waste and excess fluids from the body effectively, posing a significant threat to an individual’s health."

"Given the intricate link between diabetic nephropathy and CKD, a seamless and proactive approach to geriatric care is absolutely necessary. It’s important to create awareness about managing the complexities of CKD and diabetic nephropathy within the sphere of geriatric care," he added.

Dr. Jatin then went on to list the following:

Early Detection and Continuous Monitoring: Early detection of CKD and diabetic nephropathy in the elderly is key to effective management. Regular screenings for microalbuminuria, a marker for kidney damage, and serum creatinine levels to estimate glomerular filtration rate (GFR), which identifies the filtering rate of kidneys, can identify these conditions at an initial stage. Once detected, continuous monitoring helps track disease progression and facilitates timely interventions.

Tailored Treatment for Diabetic Nephropathy: Treatment for CKD and diabetic nephropathy in geriatric patients must be objective and tailor-made as each patient’s overall health and comorbid conditions is likely to be different. Managing blood sugar levels is critical in diabetic nephropathy to manage the condition well. In recent years, advancements in pharmacotherapy have introduced a new wave of medications that offer promising results in the treatment of diabetic kidney disease.

Notably, the emergence of SGLT2 inhibitors, such as Empagliflozin, Dapagliflozin, and Canagliflozin, has revolutionized the management of this condition. Additionally, mineralocorticoid receptor antagonists (MRAs), like Finerenone, and GLP-1 analogues, such as Semaglutide, have shown remarkable efficacy. These drugs not only improve kidney outcomes but also provide cardiovascular benefits, marking a significant leap forward in diabetic nephropathy treatment.

Similarly, controlling blood pressure with ACE inhibitors or ARBs can prevent further kidney damage in CKD. Seniors often take multiple medications, which increases the risk of harmful drug interactions. It's important to regularly review and adjust their medications to prevent any that may worsen kidney health.

Lifestyle Modifications and Integrated Care: Encouraging lifestyle modifications can significantly impact the management of CKD and diabetic nephropathy. A diet low in sodium, processed foods, and protein can reduce kidney strain. Moreover, regular physical activity, within the senior’s capability, supports overall health and blood sugar control, which is especially important in diabetic patients. However, it is important to discuss the range of activities with your physician beforehand to ensure it is aligned with your current health and comorbidities. A coordinated effort from primary care physicians, nephrologists, dietitians, and diabetes educators is necessary to create awareness about importance of routine examinations and self-management of their conditions.

[Disclaimer: The information provided in the article, including treatment suggestions shared by doctors, is intended for general informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition.]