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Study finds significantly higher rate of untreated kidney failure ... - Science Codex |
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CHICAGO – In a study that included nearly 2 millions adults in Canada, the rate of progression to untreated kidney failure was considerably higher among older adults, compared to younger individuals, according to a study in the June 20 issue of JAMA.
"Studies of the association among age, kidney function, and clinical outcomes have reported that elderly patients are less likely to develop end-stage renal disease (ESRD) compared with younger patients and are more likely to die than to progress to kidney failure even at the lowest levels of estimated glomerular filtration rate [eGFR; flow rate of filtered fluid through a kidney]," according to background information in the article. Previous studies have defined kidney failure by receipt of long-term dialysis, which reflects both disease progression and a treatment decision. "Because it is plausible that the likelihood of initiating long-term dialysis among individuals with kidney failure varies by age, earlier studies may provide an incomplete picture of the burden of advanced kidney disease in older adults, based on the incidence of long-term dialysis alone."
Brenda R. Hemmelgarn, M.D., Ph.D., of the University of Calgary, Alberta, Canada, and colleagues conducted a study to determine whether age is associated with the likelihood of treated kidney failure (renal replacement therapy: receipt of long-term dialysis or kidney transplantation), untreated kidney failure, and all-cause mortality. The study included 1,816,824 adults in Alberta, Canada, who had outpatient eGFR measured between May 2002 and March 2008, with a baseline eGFR of 15 mL/min/1.73 m2 or higher and who did not require renal replacement therapy at the beginning of the study. The primary outcome measures for the study were adjusted rates of treated kidney failure, untreated kidney failure (progression to eGFR <15 mL/min/1.73 m2 without renal replacement therapy), and death.
During a median (midpoint) follow-up of 4.4 years, 97,451 (5.4 percent) of study participants died, 3,295 (0.18 percent) developed treated kidney failure, and 3,116 (0.17 percent) developed untreated kidney failure. The researchers found that within each eGFR stratum, adjusted rates of death increased with increasing age. Also, within each eGFR stratum, rates of treated kidney failure were consistently higher among the youngest age group. "For example, in the lowest eGFR stratum (15-29 mL/min/1.73 m2), adjusted rates of treated kidney failure were more than 10-fold higher among the youngest (18-44 years) compared with the oldest (85 years or older) groups," the authors write.
The opposite results were evident for untreated kidney failure. The risk of untreated kidney failure increased with lower vs. higher eGFR categories, and this association was stronger with increasing age. "For the lowest eGFR stratum (15-29 mL/min/1.73 m2), adjusted rates of untreated kidney failure were more than 5-fold higher among the oldest age stratum (85 years or older) compared with the youngest age stratum (18-44 years)."
Rates of kidney failure overall (treated and untreated combined) demonstrated less variation across age groups.
The researchers write that their results suggest that the incidence of advanced kidney disease in the elderly may be substantially underestimated by rates of treated kidney failure alone.
"These findings have important implications for clinical practice and decision making; coupled with the finding that many older adults with advanced chronic kidney disease [CKD] are not adequately prepared for dialysis, these results suggest a need to prioritize the assessment and recognition of CKD progression among older adults. Our findings also imply that clinicians should offer dialysis to older adults who are likely to benefit from it—and should offer a positive alternative to dialysis in the form of conservative management (including end-of-life care when appropriate) for patients who are unlikely to benefit from (or prefer not to receive) long-term dialysis. Given the large number of older adults with severe CKD, these results also highlight the need for more proactive identification of older adults with CKD, assessment of their symptom burden, and development of appropriate management strategies. Finally, our study demonstrates the need to better understand the clinical significance of untreated kidney failure, the factors that influence dialysis initiation decisions in older adults, and the importance of a shared decision making process for older adults with advanced CKD."
(JAMA. 2012;307[23]:2507-2515. Available pre-embargo to the media at http://media.jamanetwork.com)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Treated and Untreated Kidney Failure in Older Adults - What's the Right Balance?
In an accompanying editorial, Manjula Kurella Tamura, M.D., M.P.H., and Wolfgang C. Winkelmayer, M.D., M.P.H., Sc.D., of the Stanford University School of Medicine, Palo Alto, Calif., (Dr. Winkelmayer is also Contributing Editor, JAMA), comment on the findings of this study.
"…the work by Hemmelgarn and colleagues highlights a potentially sizeable unmeasured burden of untreated kidney failure among older adults. It is of paramount importance to refine the current understanding of what constitutes appropriate treatment for kidney failure, which factors influence the decision-making process, and which methods are optimal for aligning treatment plans with patient goals and prognosis. Finding the right balance between overtreatment and undertreatment is challenging but necessary. This important scientific and ethical debate can no longer be avoided, for both individual and societal good."
(JAMA. 2012;307[23]:2545-2546. Available pre-embargo to the media at http://media.jamanetwork.com)
Editor's Note: Please see the article for additional information, including other affiliations, financial disclosures, funding and support, etc.
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Kidney Failure Tx Less Likely for Seniors - MedPage Today |
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By Todd Neale, Senior Staff Writer, MedPage Today
Action Points
Among patients with similar renal function, treatment for kidney failure was more likely in younger patients than in their older counterparts, a retrospective study out of Canada showed.
This held true across the range of estimated glomerular filtration rate (eGFR), according to Brenda Hemmelgarn, MD, PhD, of the University of Calgary in Alberta, and colleagues.
For example, in the patients with the worst kidney function (eGFR of 15 to 29 mL/min/1.73 m2), the adjusted rate of treated kidney failure was 24 per 1,000 person-years among those ages 18 to 44 and 1.53 per 1,000 person-years among those age 85 and older (P<0.001, 95% CI 0.59 to 3.99).
Conversely, among those with the worst kidney function at baseline, rates for the oldest compared with the youngest patients were 19.95 (95% CI 15.79 to 25.19) versus 3.53 (95% CI 1.56 to 8.01) per 1,000 person-years, respectively (P<0.001).
These results, reported in the June 20 issue of the Journal of the American Medical Association, "suggest that the incidence of advanced kidney disease in the elderly may be substantially underestimated by rates of treated kidney failure alone and that untreated kidney failure may be more common than initiation of renal replacement at older ages," the authors wrote.
"These findings have important implications for clinical practice and decision making," they continued. "Coupled with the finding that many older adults with advanced chronic kidney disease are not adequately prepared for dialysis, these results suggest a need to prioritize the assessment and recognition of chronic kidney disease progression among older adults."
Previous studies of kidney failure among older adults have focused on the receipt of dialysis, a measure of both disease progression and treatment decisions. That can underestimate the actual burden of disease, however, because it leaves out the patients who do not receive treatment.
To explore the relationship between age and rates of treated and untreated kidney failure, the researchers retrospectively looked at data from more than 1.8 million adults living in Alberta who had their kidney function measured from May 2002 to March 2008. All had an eGFR of 15 mL/min/1.73 m2 or higher and did not require renal replacement therapy at baseline.
The main outcomes were treated kidney failure (receipt of either dialysis or a kidney transplant), untreated kidney failure (progression to an eGFR of less than 15 mL/min/1.73 m2 without renal replacement therapy), and all-cause death.
Through a median follow-up of 4.4 years, 5.36% of the patients died, 0.18% developed kidney failure that was treated, and 0.17% developed kidney failure that was untreated.
The study "highlights a potentially sizable unmeasured burden of untreated kidney failure among older adults," Manjula Kurella Tamura, MD, MPH, and Wolfgang Winkelmayer, MD, MPH, of Stanford University in Stanford, Calif., wrote in an accompanying editorial.
"It is of paramount importance to refine the current understanding of what constitutes appropriate treatment for kidney failure, which factors influence the decision-making process, and which methods are optimal for aligning treatment plans with patient goals and prognosis," they wrote.
Hemmelgarn and colleagues acknowledged some limitations of the study, including the inability to assess the reasons for not receiving treatment, the exclusion of patients who did not have at least one serum creatinine measurement, and the lack of long-term follow-up to look for clinical events.
The study was supported by the Canadian Institutes of Health Research (CIHR) and by an interdisciplinary team grant from Alberta Innovates-Health Solutions (AI-HS). Hemmelgarn and two of her co-authors were supported by career salary awards from AI-HS. Hemmelgarn was supported by the Roy and Vi Baay Chair in Kidney Research. Her co-authors reported additional support from a Government of Canada Research Chair and Fellowship Awards from CIHR and the Canadian Diabetes Association.
Hemmelgarn reported that she had no conflicts of interest. Her co-authors reported relationships with UpToDate and Amgen.
Kurella Tamura is supported by a Paul B. Beeson Award from the National Institute on Aging. She reported having served as a scientific advisor to Amgen. Winkelmayer reported having served as a scientific advisor to Affymax/Takeda, Amgen, Fibrogen/Astellas, GlaxoSmithKline, and Vifor Fresenius Medical Care Renal Pharma Ltd.
Primary source:Journal of the American Medical Association
Source reference:
Hemmelgarn B, et al "Rates of treated and untreated kidney failure in older versus younger adults" JAMA 2012; 307:2507-2515.
Additional source: Journal of the American Medical Association
Source reference:
Kurella Tamura M, Winkelmayer W "Treated and untreated kidney failure in older adults: what's the right balance?" JAMA 2012; 307: 2545-2546.
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Todd Neale
Senior Staff Writer
Todd Neale, MedPage Today Staff Writer, got his start in journalism at Audubon Magazine and made a stop in directory publishing before landing at MedPage Today. He received a B.S. in biology from the University of Massachusetts Amherst and an M.A. in journalism from the Science, Health, and Environmental Reporting program at New York University. He is based at MedPage Today headquarters in Little Falls, N.J.
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Study Finds Significantly Higher Rate of Untreated Kidney Failure ... - Newswise (press release) |
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Newswise — CHICAGO – In a study that included nearly 2 millions adults in Canada, the rate of progression to untreated kidney failure was considerably higher among older adults, compared to younger individuals, according to a study in the June 20 issue of JAMA.
"Studies of the association among age, kidney function, and clinical outcomes have reported that elderly patients are less likely to develop end-stage renal disease (ESRD) compared with younger patients and are more likely to die than to progress to kidney failure even at the lowest levels of estimated glomerular filtration rate [eGFR; flow rate of filtered fluid through a kidney]," according to background information in the article. Previous studies have defined kidney failure by receipt of long-term dialysis, which reflects both disease progression and a treatment decision. "Because it is plausible that the likelihood of initiating long-term dialysis among individuals with kidney failure varies by age, earlier studies may provide an incomplete picture of the burden of advanced kidney disease in older adults, based on the incidence of long-term dialysis alone."
Brenda R. Hemmelgarn, M.D., Ph.D., of the University of Calgary, Alberta, Canada, and colleagues conducted a study to determine whether age is associated with the likelihood of treated kidney failure (renal replacement therapy: receipt of long-term dialysis or kidney transplantation), untreated kidney failure, and all-cause mortality. The study included 1,816,824 adults in Alberta, Canada, who had outpatient eGFR measured between May 2002 and March 2008, with a baseline eGFR of 15 mL/min/1.73 m2 or higher and who did not require renal replacement therapy at the beginning of the study. The primary outcome measures for the study were adjusted rates of treated kidney failure, untreated kidney failure (progression to eGFR
During a median (midpoint) follow-up of 4.4 years, 97,451 (5.4 percent) of study participants died, 3,295 (0.18 percent) developed treated kidney failure, and 3,116 (0.17 percent) developed untreated kidney failure. The researchers found that within each eGFR stratum, adjusted rates of death increased with increasing age. Also, within each eGFR stratum, rates of treated kidney failure were consistently higher among the youngest age group. "For example, in the lowest eGFR stratum (15-29 mL/min/1.73 m2), adjusted rates of treated kidney failure were more than 10-fold higher among the youngest (18-44 years) compared with the oldest (85 years or older) groups," the authors write.
The opposite results were evident for untreated kidney failure. The risk of untreated kidney failure increased with lower vs. higher eGFR categories, and this association was stronger with increasing age. "For the lowest eGFR stratum (15-29 mL/min/1.73 m2), adjusted rates of untreated kidney failure were more than 5-fold higher among the oldest age stratum (85 years or older) compared with the youngest age stratum (18-44 years)."
Rates of kidney failure overall (treated and untreated combined) demonstrated less variation across age groups.
The researchers write that their results suggest that the incidence of advanced kidney disease in the elderly may be substantially underestimated by rates of treated kidney failure alone.
"These findings have important implications for clinical practice and decision making; coupled with the finding that many older adults with advanced chronic kidney disease [CKD] are not adequately prepared for dialysis, these results suggest a need to prioritize the assessment and recognition of CKD progression among older adults. Our findings also imply that clinicians should offer dialysis to older adults who are likely to benefit from it—and should offer a positive alternative to dialysis in the form of conservative management (including end-of-life care when appropriate) for patients who are unlikely to benefit from (or prefer not to receive) long-term dialysis. Given the large number of older adults with severe CKD, these results also highlight the need for more proactive identification of older adults with CKD, assessment of their symptom burden, and development of appropriate management strategies. Finally, our study demonstrates the need to better understand the clinical significance of untreated kidney failure, the factors that influence dialysis initiation decisions in older adults, and the importance of a shared decision making process for older adults with advanced CKD."
(JAMA. 2012;307[23]:2507-2515. Available pre-embargo to the media at http://media.jamanetwork.com)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Treated and Untreated Kidney Failure in Older Adults - What's the Right Balance?
In an accompanying editorial, Manjula Kurella Tamura, M.D., M.P.H., and Wolfgang C. Winkelmayer, M.D., M.P.H., Sc.D., of the Stanford University School of Medicine, Palo Alto, Calif., (Dr. Winkelmayer is also Contributing Editor, JAMA), comment on the findings of this study.
"…the work by Hemmelgarn and colleagues highlights a potentially sizeable unmeasured burden of untreated kidney failure among older adults. It is of paramount importance to refine the current understanding of what constitutes appropriate treatment for kidney failure, which factors influence the decision-making process, and which methods are optimal for aligning treatment plans with patient goals and prognosis. Finding the right balance between overtreatment and undertreatment is challenging but necessary. This important scientific and ethical debate can no longer be avoided, for both individual and societal good."
(JAMA. 2012;307[23]:2545-2546. Available pre-embargo to the media at http://media.jamanetwork.com)
Editor's Note: Please see the article for additional information, including other affiliations, financial disclosures, funding and support, etc.
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Medicare covers kidney disease - Redwood Times |
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By David Sayen
A diagnosis of kidney failure could be a real shock. And it’s becoming more common as the number of Americans with diabetes and high blood pressure grows. But even with this serious diagnosis you can survive and move on.
Medicare can help. The program helps pay for kidney dialysis as well as kidney transplants.
Chronic kidney disease is a serious health problem in the United States. In 2010, more than 20 million Americans aged 20 and older had this disease.
And in 2008, nearly 550,000 Americans were getting treated for end-stage renal disease, or ESRD, which is permanent kidney failure.
Most people have to be at least 65 years old to get Medicare. But people with ESRD can get Medicare at any age. Even children with ESRD can enroll in Medicare.
ESRD is treated by dialysis, a process which cleans your blood when your kidneys don’t work. It gets rid of harmful waste, extra salt, and fluids that build up in your body. It also helps control blood pressure and helps your body keep the right amount of fluids.
Dialysis treatments help you feel better and live longer - but they aren’t a cure for permanent kidney failure.
Medicare covers a number of things related to dialysis.
If you’re admitted to a hospital for special care, Medicare covers inpatient dialysis treatments under Part A, which is hospital insurance.
Medicare Part B covers outpatient dialysis treatments and doctors’ fees for outpatient care.
Part B also pays for self-dialysis training, which includes instruction for you and the person helping you with your home dialysis treatments.
And Part B covers home dialysis equipment and supplies - like the machine and water treatment system - as well as most drugs for home dialysis.
How much would you have to pay for dialysis in a Medicare-certified facility? If you have Original Medicare, you’d pay 20% of the Medicare-approved amount for all covered services.
Medicare pays the other 80%.
Dialysis and kidney transplants are paid through Original Medicare.
In most cases, you can’t join a Medicare Advantage plan if you have end-stage renal disease.
Keep in mind that dialysis can be done in your own home or in a Medicare-certified facility.
Ask your kidney doctor what facility he or she works with. Or you can look for a facility on Medicare’s “Dialysis Facility Compare” website.
It’s located at www.medicare.gov/dialysis.
The website has important information such as addresses and phone numbers, how far certain facilities are from you, and what kind of dialysis services the facilities offer.
You also can compare facilities by certain quality-of-care information.
If you don’t have a computer, you can call us, toll-free, at 1-800-MEDICARE (1-800-633-4227).
Medicare Part A also helps pay for hospital inpatient services if you need a kidney transplant.
Medicare will help cover the costs of finding the proper kidney for your transplant, and the full cost of care for your kidney donor.
For more details on transplants, please consult our pamphlet, “Medicare Coverage of Kidney Dialysis & Kidney Transplant Services” (CMS Product No. 10128).
It’s available online or by calling 1-800-MEDICARE.
David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).
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