It follows, therefore, that proper treatment of dyslipidemia and other risk factors for the development of CVD is necessary. Special care should be given to the treatment of elderly patients with CKD, especially those with advanced CKD and ESRD, with continuous evaluation of the lipid abnormalities which increase risks in each patient. Additionally, there is a need for more specific research into dyslipidemia in CKD sufferers among the elderly population, in relation to the progression of kidney and cardiovascular diseases. Dietary changes in individuals with CKD have demonstrated some benefits for the control and prevention of arterial hypertension, in delaying decrease in renal function and in the relief of uremic symptoms.
However, in relation to the control of arterial hypertension, there is a focus on pharmacological treatment, and it is therefore important to promote measures to encourage adequate nutrition, especially regarding the control of salt intake by chronic renal patients.
One of the main objectives of nutrition therapy in cases of CKD is its contribution to alleviating the clinical manifestations of uremic syndrome. In this context, protein restriction can be beneficial in improving uremic symptoms by reducing the accumulation of toxic nitrogen compounds, 27 although it can lead to loss of lean mass and malnutrition, more frequently in elderly patients.
Although more recent studies have shown that protein restriction benefits individuals with CKD, a more careful approach is required for elderly patients.
Chronic kidney disease
In this population, a hypoproteic diet can contribute to the development of sarcopenia, and to frailty and functional impairment, resulting in deprivation, frustration, and social isolation. It is also important that a careful nutritional assessment is carried out when an elderly individual begins a restrictive diet, 14 along with nutritional monitoring so that nutritional status is not adversely affected by the recommended protein restriction.
The combination of a low protein diet with the supplementation of essential amino acids or ketoacids is an alternative to conventional protein restriction 0. However, despite being a realistic, safe and effective diet for the postponement of dialysis, including for the elderly, it must be accompanied by regular monitoring of patients by a nephrologist and a nutritionist in order to avoid nutritional risk. The effects of dietary protein restriction on the prevention of CKD progression have been notoriously controversial because of the design characteristics of the studies in question and also because of inconclusive and contradictory results returned by randomized controlled trials.
In a meta-analysis of randomized controlled trials that determined the effect of hypoproteic diets on renal function in patients with diabetic nephropathy, it is suggested that, despite the limitations of the studies, a restricted protein diet was not associated with a significant improvement in renal function markers 29 and thus early protein restriction in the diet of these patients could contribute to the development of severe malnutrition.
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These results point to the need to carry out a greater number of methodologically sophisticated studies seeking to clarify the benefits of and the recommendations for protein restriction in elderly patients with CKD. In fact, on viewing the results of epidemiological studies regarding the relationship between lifestyle related variables diet, obesity, exercise and smoking and CKD, 12 it was found that most did not emphasize lifestyle changes. Among the studies evaluated, only one mentions these variables, while a second adds only a little information regarding the importance of weight loss and abstinence from smoking, without recommending specific measures for the elderly.
Therefore, more effective study of these aspects in elderly patients with CKD is necessary, particularly given the worldwide increase in the elderly population and in CKD prevalence. Also in relation to lifestyle, specifically with regard to weight loss, James et al.
Symptoms, causes, and treatment of chronic kidney disease
The use of BMI as a tool for assessment of nutritional status in patients with CKD has been the subject of discussion in literature. The authors offer various explanations for this argument: 30 a BMI does not differentiate between body compartments such as fat and muscle; b it does not capture changes in body composition associated with aging; c there is no differentiation between differences in body shape between genders; d it does not distinguish body fat distribution - central and peripheral; e fluid overload in CKD confuses BMI assessment.
Regarding WC, procuring a precise measurement can be very difficult in very obese patients. Therefore, given the importance of body composition in the prognosis of patients with CKD and the use of BMI and WC in clinical practice should not occur in isolation, but in combination with other methods and tools to assess nutritional status and body composition, in order to establish an adequate nutritional diagnosis.
Various patient care models have been proposed. The more traditionally employed approach is guided by the course of the progression of the disease, while a more individualized and patient-centered method is slowly gaining ground, as is a multidisciplinary approach. The elderly do not always prefer care that prolongs life, especially when it comes at the expense of comfort.
They tend to prefer to remain independent in their normal daily activities and to avoid becoming a burden to their families.
An important feature of the individualized approach is that it can always accommodate strategies for treatment of the underlying disease as long as they align with the patient's objectives and preferences. As for the multidisciplinary approach, it is worth mentioning that even though many nephrologists are currently experiencing the benefits of this care in chronic kidney disease clinics, convincing evidence for its efficacy from relevant clinical results is still scarce 2 and the majority of studies that assess this approach contain a limited representation of elderly patients.
However, given the complexity of CKD, coupled with the clinical problems inherent in aging, the interdisciplinary care model, in facilitating multidimensional assessment of patients, emerges as the best form of treatment for elderly CKD sufferers. However, although multidisciplinary and individualized patient-centered approaches seem to bring many benefits in patient care, it should be remembered that doctors and other health professionals may be inadequately prepared to identify the preferences and goals of patients and incorporate these into treatment strategies.
Furthermore, there may be little evidence to support treatment decisions in cases where the specific objectives of an individual patient have not yet been studied. Regarding the early referral of CKD patients to a specialist, while this procedure appears to presents beneficial results, the number of practicing nephrologists is insufficient to care for all patients with CKD. According to a study carried out by Rothberg et al. Therefore, efforts should focus on helping physicians better identify patients with decreased GFR and on ensuring that nephrologists and other experts adopt a broader view of care for CKD patients.
Symptoms of CKD
Thus, the issue of referral to a nephrologist involves two aspects. Firstly, the number of specialists does not match patient demand and it is not necessary to refer all CKD patients, especially those in the early stages of the illness, and secondly, those patients who could be treated successfully at the primary care stage are often treated by ill-prepared doctors.
To deal with the above issues, further educational efforts are needed to increase the knowledge of professionals regarding clinical guidelines on CKD, with the aim of improving management of the disease and clinical outcomes. In addition, more research into new methods for the identification of cases of the illness and the provision of care in different contexts is necessary due to the high and growing global prevalence of CKD.
Based the findings of the present study, it can be concluded that treatment for patients with chronic kidney disease is limited and includes therapeutic interventions involving control of blood pressure, diabetes and dyslipidemia, dietary changes, weight reduction and stopping smoking. However, there are few treatments aimed directly at the physiopathological process of renal failure, 12 possibly due to the complexity of pathophysiological treatment, since it involves the replacement of normal tissue by a fibrous equivalent, which is an irreversible process.
Thus, this treatment is focused on preventing glomerular sclerosis and interstitial fibrosis and its progression.
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The therapeutic focus is on the treatment of the underlying illnesses and complications of kidney disease. If diabetes and high blood pressure were treated properly, it would not only reduce the risk of chronic kidney disease and end stage renal disease, but also the risk of mortality associated with these illnesses. It is worth reemphasizing that were renal disease included in the context of primary health care, referral to specialists would be possible and primary care physicians could manage patients with chronic kidney disease in its early stages.
Although there is an apparent effort by researchers to institute more suitable therapeutic approaches for the management of chronic kidney disease, there is still little evidence of interventions that improve the chances of survival for elderly sufferers. Some interventions, however, do prevent its exacerbation and delay its progression. Thus, the treatment of patients from the elderly population presents a set of characteristics which must be more clearly understood and individualized, making necessary further randomized and controlled long-term studies of elderly individuals with chronic kidney disease, in order to discover the most effective therapeutic procedures for the control of this illness.
Finally, in treatment of elderly patients with chronic kidney disease, the greatest possible delay on progression to the terminal stages of the illness must be sought, given that dialysis is accompanied by negative impact and limitations that translate into a reduced quality of life for patients. Kidney Int ;3 1 Early recognition and prevention of chronic kidney disease. Lancet ; Renin-angiotensin-aldosterone system blockade effects on the kidney in the elderly: benefits and limitation. Clin J Am Soc Nephrol ;5 7 Recognition and management of chronic kidney disease in an elderly ambulatory population.
J Gen Intern Med ;23 8 Awareness and knowledge of clinical practice guidelines for CKD among internal medicine residents: A national online survey. Am J Kidney Dis ;52 6 Stevens PE, Levin A. Ann Intern Med ; 11 Conceptual Model of CKD: applications and implications. Am J Kidney Dis ;53 Suppl 3 World Population Prospects: the Revision.
New York: United Nations; Renal function assessment in the era of chronic kidney disease: Renewed emphasis on renal function centered patient care. J Urol ; 2 Managing older adults with CKD: individualized versus disease-based approaches. Am J Kidney Dis ;59 2 Treating elderly people with diabetes and stages 3 and 5 chronic kidney disease.
Clin J Am Soc Nephrol ;3 4 Chronic kidney disease and diabetes. Maturitas ;71 2 CKD progression and mortality among older patients with diabetes. Am J Kidney Dis ;46 3 Light and shadows of dietary protein restriction in elderly with chronic kidney disease. Nutrition ;29 9 Disorders of lipid metabolism and chronic kidney disease in the elderly. Semin Nephrol ;29 6 Safety of statins. Indian J Endocrinol Metab ;17 4 Fouque D, Guebre-Egziabher F. Do Low-Protein diets work in chronic kidney disease patients?
Semin Nephrol ;29 1 Kiberd B. The chronic kidney disease epidemic: stepping back and looking forward. J Am Soc Nephrol ;17 11 National Kidney Foundation. Am J Kidney Dis ;39 Supl 1 Diabetes mellitus and kidney disease in the elderly. Nefrologia ;34 3 Metformin use in chronic kidney disease: new evidence to guide dosing. QJM ; 11 Ioannidis I. Diabetes treatment in patients with renal disease: Is the landscape clear enough?
World J Diabet ;5 5 Abreu PF. Barueri: Manole; Sociedade Brasileira de Cardiologia. Arq Bras Cardiol ; 4 Supp 1 United States Renal Data System. Vol 2. J Bras Nefrol ;32 1 Cuppari L. Red blood cells contain hemoglobin. This is a protein with a lot of iron that gives your blood its red color.
Chronic kidney disease - Wikipedia
Your doctor learns if you have anemia and how serious it is by measuring your hemoglobin level. If a blood test shows that you have anemia, you will need to decide if you should take drugs to help your body make new red blood cells. These drugs are called erythropoiesis-stimulating agents ESAs. ESAs are sometimes used to raise the number of red blood cells to normal, even when a patient does not have severe anemia or symptoms.
But research shows that the drugs do not help people with chronic kidney disease live longer. And when they are used aggressively, they can actually raise the risk of death by causing heart failure, heart attack, or stroke. ESAs also cost hundreds of dollars for each dose. Bottom line : You should consider an ESA only if you have symptoms of anemia, such as feeling tired or short of breath, and you also have a very low hemoglobin level. If you and your doctor decide to try an ESA, you should take the lowest dose that relieves your symptoms and keeps your hemoglobin level just high enough that you do not need blood transfusions.
Tell your doctor all your symptoms and talk about how they will improve. A second important decision you may have to make is how to treat other health problems you have. This is when a catheter, or thin tube, is inserted in your inner elbow and threaded up a vein until it reaches your heart. However, a PICC can lead to problems if you have chronic kidney disease.
This is because it is important to protect the veins in your arms in case you need hemodialysis if your kidney disease becomes advanced. However, when a PICC is inserted in a vein, it causes scarring. A scarred vein cannot later be used for hemodialysis. See Hemodialysis section below. Bottom line : For certain treatments, like getting chemotherapy for cancer, a doctor or nurse will have to insert a PICC. But if your kidney disease reaches stage 3 or higher and a doctor suggests a PICC in your arm, ask for a second opinion from a doctor who specializes in kidney diseases.
Often, you can have the PICC put in a vein in your neck instead. This saves the veins in your arms for use with hemodialysis. Whether to have hemodialysis, is another important decision you may have to make. This is something you may have to consider if your kidneys get close to failing. Dialysis takes over some of the things your kidneys normally do, like removing waste and keeping a safe balance of water and salts in your blood.
Stage 2 CKD
But hemodialysis is not a good idea for everyone with advanced kidney disease. In some cases, hemodialysis does not relieve your symptoms. And it may not help you do your normal activities, stay independent, or live longer. That is especially true the older you are, and if you also have a heart disease or another condition that can shorten your life.
In one study of more than 3, nursing home residents, more than half died within a year of starting hemodialysis. Of the people who survived, most felt a sudden drop in their ability to do routine tasks on their own. Also, there is no benefit to starting hemodialysis when your kidney disease is at an early stage. This practice has become common, but it may not help you live longer or feel better.
The last issue to keep in mind is that hemodialysis is hard on a person. You usually have to go a hemodialysis center at least three days a week, and each treatment session lasts three to five hours. Common side effects of hemodialysis include headaches, nausea, and feeling tired. In surveys of older adults on long-term hemo-dialysis, over half of them say they wish they had not started the treatment. Many say they only chose hemodialysis because their doctors wanted them to.
Bottom line : You should talk with your doctor, your family, and any other caregivers you have before you decide if long-term hemodialysis is the right choice for you. Ask your doctor to tell you all the benefits and risks of hemodialysis.
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