The Aging Adult and Chronic Kidney Disease

Abstract

The demographics of population growth in the United States is shifting. From 2002 to 2016, the population grew from 287 million to 323 million and life expectancy increased from 76.8 to 78.8 years.Within this growth, there has been a drop in both fertility rate and mortality rate, resulting in significant growth of the elderly population.As reported by the US Census Bureau, by the year 2030, all baby boomers will be older than age 65. The size of the older population will grow such that by 2035, there will be 78 million people 65 years and older compared to 76.7million under the age of 18. The report goes on to say that for the first time in US history, the number of older people will outnumber children.

The editors acknowledge the contribution of Denis Fouque and Julie Barboza to this chapter in Nutrition in Kidney Disease, Second Edition, Nutrition and Health, DOI https://doi.org/10.1007/978-1-62703-685-6_1, © Springer Science+Business Media New York 2014.

Appendices

Case Study

C.M.D. is an 80-year-old Hispanic female, widower, with CKD late stage 4, early stage 5 (eGFR 12–16%), a history of hypertension (HTN), congestive heart failure stage 3, atrial fibrillation, mitral valve stenosis – not an operable candidate, and failure to thrive. Her oxygenation is stable on room air. C.M.D. does have a reported residual kidney and produces a urine output of approximately 650 cc per day. She lives with her daughter’s family, which includes her son-in-law and three young grandchildren. There is a reported concern of food insecurity by the social worker. C.M.D. denies nausea, vomiting, diarrhea, abdominal pain, or any symptoms of acute illness. Her prescribed medications are as follows: 40 mg furosemide twice daily, sevelamer carbonate 800 mg three times daily with meals, metoprolol 25 mg qd, spirolactone 25 mg per day, apixaban 2.5 mg twice daily, nephrovite one tablet daily, and cholecalciferol 2000 units daily. C.M.D. has verbalized that she is unsure if she wants to start renal replacement therapy and does not understand what dialysis will do for her.

Objective– height: 64 inches; weight: 128 lb; reported weight change is 10 lb of unintentional weight gain over the past 2 weeks. She reports that her appetite is improving. Her sitting blood pressure is 128/60 mmHg. Labs: BUN 65 mg/dL, Cr 3.6 mg/dL, Na⁺ 136 mEq/L, K⁺4.8 mEq/L, CO₂ 22 mEq/L, RBC 3.80, Hgb 11.1 g/dL, Hct 34.4%, total cholesterol 201 mg/dL, TRG 180 mg/dL, HDL 40 mg/dL, LDL 130 mg/dL, Ca²⁺9.0 mg/dL, phosphate 6.0 mg/dL, albumin 2.5 gm/dL, serum parathyroid hormone 475 pg/mL, and vitamin D level (25OH) 24 ng/mL.

Case Questions and Answers

• 1. What are some of the immediate factors that need to be considered in completing C.M.D.’s nutrition assessment?

  Answer:

  • Recent weight gain; need to evaluate volume status; is this loss of residual renal function, worsening CHF, exacerbated by high sodium intake, non adherence to medications; does C.M.D. have insurance adequate to purchase medications and are they being purchased and taken?

  • Hypoalbuminemia: is dilution a factor if patient is hypervolemic?

  • Is diuresis being accomplished?

  • What is C.M.D.’s magnesium level? Why is magnesium important?

  • When did C.M.D. last have evaluation by cardiology?

  • Obtaining a 24-hour urine collection for creatinine clearance would be helpful in evaluating C.M.D.’s overall kidney function. Her weight is up on diuretics and if her residual kidney function has declined and she cannot obtain a negative fluid balance, renal replacement therapy is a consideration while undergoing above assessments.

  • What is C.M.D.’s overall adequacy of nutrient intake?

  • Definition of C.M.D.’s sodium intake and total fluid intake needs to be quantified.

• 2. Which eGFR equation would be ideal to use for estimate C.M.D.’s kidney function and why?

  Answer: CKD-EPI cystatin C or CKD-EPI Cr-cystatin C: more accurate choice for elderly and individuals with reduced mass.

• 3. What are some areas of concern related to this patient’s psychosocial situation?

  Answer:

  • Financial support: Does patient have financial support to purchase medications? Food?

  • Education regarding renal replacement therapy is needed with patient and family for C.M.D. to decide whether to pursue dialysis. This evaluation is recommended to include the cardiologist to ascertain cardiovascular mortality risk and prognosis while C.M.D. is considering decisions regarding end-of-life care and quality of life. If C.M.D. decides to pursue renal replacement therapy, home peritoneal dialysis in addition to home and in-center hemodialysis are best to be included. C.M.D. may benefit from peritoneal dialysis due to her cardiovascular status. Code status and Advanced Directives are recommended to be identified and documented.

• 4. What nutrition assessment and therapies are indicated based on this presenting information?

  Answer:

  • Evaluation of food intake for estimation of quality and quantity of nutrients.

  • Determine if a fluid restriction is indicated by evaluating total fluid intake.

  • How is her dental health? Can C.M.D. chew food properly?

  • Evaluate visceral muscle stores with anthropometrics.

  • Evaluate for frailty.

  • Evaluate for sarcopenia – grip strength could prove helpful.

  • Is protein intake adequate? What about calories?

  • Is phosphorus elevated due to diet intake, lack of binders, needing more binders, high phosphorus food intake?

  • Is vitamin D low due to not taking the supplement or not having the supplement to take or does C.M.D. need more vitamin D?