Table 1.

Unique characteristics of kidney disease in the elderly

Clinical TopicCharacteristic in ElderlyRecommendations/Key Questions
Diabetes
    glycemic controlLess likely to benefit from long-term glycemic controlCloser monitoring of glycemic control and question of risk/benefit for Hgb A1C < 7.0
More likely to suffer from hypoglycemia
Higher risk of drug-associated hypoglycemia (33)
    BP agents and goalsHigher risk for significant decreases in BP (34,35)Caution when prescribing BP medications, avoid very low BP
Concerns over lack of benefit and side effects of ACEIs/ARBs (36)Caution when prescribing ACEIs/ARBs
HTN
    target goalCV events, cognitive insufficiency, disability, and mortality may pose a greater risk to the elderly patient than progression of kidney disease (37,38)Consider other outcomes as goal for BP control rather than delay progression of kidney disease
    specific agentAdministration of ACEIs/ARBs can cause AKI and hyperkalemia with a higher incidence in the elderly (39)Need for extra laboratory testing after initiation or dose changes of ACEIs/ARBs
Dietary modification/chronic administration of ion-exchange resin may be needed
Limit use of other medications that raise serum potassium
GNRates of albuminuria increase with age (40)Does significance of albuminuria differ in older versus younger patients?
Elderly with proteinuria are at a significant risk of loss of renal function over 5 years (41)
Albuminuria associated with increased risk for dementia, HTN, and CV disease (41)
Clinical manifestations of glomerular diseases are often blunted in elderlyQuestion of whether more biopsies should be done in this group and appropriate risk/benefit ratio for treatment with aggressive immunosuppression
Cardiac diseaseDiagnosing acute coronary syndromes in older patients with CKD can be challenging because noninvasive tests have different sensitivities and specificities (42), unusual clinical presentations (43), and difficult interpretation of standard laboratory markers (44)Meticulous effort for workup of acute coronary syndrome in elderly with CKD
Vascular diseasesIncreased incidence of renal artery stenosis (45)Need for markers to predict benefit of interventions for renal vascular disease, caution when using ACEIs/ARBs
Carotid baroreflex response is often blunted, and vasodilator antihypertensive medications may lead to dizziness and orthostatic hypotensionCaution when using vasodilators
AnemiaHigh prevalence of anemia (46)Question of goal Hgb levels, especially if the patient has a history of any kind of vascular disease, prothrombotic state such as malignancy, or poorly controlled HTN
Unique causes of anemia as inadequate nutrition and malignancy, mainly GI malignancies and hematologic malignanciesAdequate diagnostic workup of anemia may reveal significant disease
AKIAKI is often iatrogenic and multifactorial with multiple predisposing featuresCareful and comprehensive clinical exam of elderly with AKI
    prerenalDecrease in cardiac output or effective circulating volume and dehydration are common with unreliable clinical signs and symptoms of dehydration (47)Prophylactic measures before intravascular or radiological procedures
    renal
        renovascular diseasesCholesterol embolization after intravascular procedures or surgery or rarely acute renal artery thrombosisAvoid NSAIDs, caution with ACEIs/ARBs in high-risk patients
        hemodynamicDrugs that impair renal autoregulation or interfere with the vasodilatory capacity as NSAIDs, ACEIs, and ARBs (48,49)Adequate supportive measure
        ATNSeveral chronic premorbid conditions such as congestive heart failure, HTN, and diabetes predispose to the development of severe tubular injury.
Elderly patients more frequently undergo significant CV surgery and are more susceptible to complications leading to ATNAvoid polypharmacy, frequent review of medication list
        AINElderly patients are at increased risk secondary to the large number of medications that they may be taking.High degree of suspicion for diagnosis
        GNElderly patients have a higher incidence of pANCA and anti-GBM associated with RPGN (50)
    postrenalIncreased incidence of postrenal obstructive AKI (51,52)Noninvasive imaging study of the kidney/urinary tract is critical
  • ACEIs, angiotensin converting enzyme inhibitors; ARBs angiotensin receptor blockers; AKI, acute kidney injury; AIN, acute interstitial nephritis; ATN, acute tubular necrosis; BP, blood pressure; CV cardiovascular; GBM, glomerular basement membrane; GI, gastrointestinal; Hgb, hemoglobin; HTN, hypertension; NSAIDs, nonsteroidal anti-inflammatory agents; pANCA, perinuclear anti-neutrophil cytoplasmic antibody; RPGN, rapidly progressive GN.