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The Mount Sinai Journal of Medicine vol. 70 no 1 Jan.2003
21%Medicare 2010 50+ 1900-2040
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Carlos Musso, Int Urol Nephrol 34:2002Geriatrics from the Beginning, Glosa 2001 - : -- -
Carlos Musso, Int Urol Nephrol 34:2002Geriatrics from the Beginning, Glosa 2001 - : -- -
- 1985: 1 1990: 1990: : Int J Urol Nephrol1994: 1 John Hartford Foundation 2000-2003: 2004: Geriatric CME credits
ACGME Accreditation Cancel for Graduate Medical Education
. . . Geriatric Nephrology be added to the core curriculum
. . . Fellows must have formal instruction clinical experience in disorders related to the aging kidney and unirary trait . . .
Renal ASN Week:2-day courses on Geriatric Nephrology 2008,2009,2010,2011Donald Kohan: Chair of the Commitee D.G. Oreopoulos: Co-Chair
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Wendy EHoy et al. Kidney International (2003) 63, S31S37
Wendy EHoy et al. Kidney International (2003) 63, S31S37
Elderly NeprhosclerosisRule AD, et al: Ann Int Med 152:2010n: 1203 Kidney Donors
Age GroupCrude Prevalence (95% Cl), %Crude Prevalence After Exclusion of Persons Who Received Therapy for Hypertension 18-29 y 2.7 2.7 %30-39 y 16 15 40-49 y 28 26 50-59 y 44 42 60-69 y 58 55 70-77 y 79 75 Overall 28 26
Characteristics Assoc with NephrosclerosisRule AD., et al: Ann Int Med 152:201024 hours urinary AE: P:0.010Nocturnal hypertension: P:0.019Hypertension P:0.002...a 32 mg increase in urinary albumin excretion,
a 21 mmHg increase in nocturnal diastole blood pressure,
a 32 mmHg increase in nocturnal systolic blood pressure and treated hypertension,
..has the same association with nephrosclerosis as an 8 year increase in age...
,
-E. M. Darmady et al. J. Path.-Vol. 109 (1973)
B. Kappel and S. Olsen , Virchows Arch. Path. Anat. Histol. 387, (1980)
Xin JZhou et al. Kidn Int (2008) 74, 710720
10%/ 40
0.87ml/min/year
Spitzer A : J Clin Invest 1974;53
(10-and 30-mo-old rats) Challah, M. et al. Am J Physiol Heart Circ Physiol 273:1997
Age and the Absolute GFR of males and Females Berg, U. B. Nephrol. Dial. Transplant. 2006 21:2577-2582
Barton, M. Nephrol. Dial. Transplant. 2005. 20
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MDRDLevey AS et al Ann Intern Med 130:461-470, 1999
7747 >65
Estimating renal function in older people: a comparison of three formulas Pedone C et al Age and aging 2006;35:121-126 CG, MDRD1, MDRD2 51.2ml/min 54.9ml/min 64.7ml/min ..
1 mg% GFR 120ml/min 20
eGFR Am J Kidn Dis,Vol 49,No 2,2007 GFR 60ml/min 80
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Pedone C et al Age and aging 2006;35:121-126 Epo Vi-D
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- GFRLongitudinal Baltimore Study1958-1981Lindeman MD., et al: J Am Soc Geriat 1985. . . 254 GFRml, 0,75 /min/ 70% / . . . 30%
the decline in Renal function with age can be clinically insignificant unless other acute/chrome diseases that affect the RF are overlapped:arterial hypertensiondiabetes mellitus (II)CHF
Coresh J., et al: JAMA 298:2007Zhang L., et al: Am J Kidn Dis 51:2008 : 10% China 4% USA
Zhang Q., et al: MBC Public Health 8/2010 26 : USA, Europe, Asia
. . . >64 23.4%-35.8% GFR MDRD vs CCG
eGFR 40% 52% Tertiary Care Hospitals - 63.2 vs 59.3 300% e-GFR
35% e-GFRNoble E. Et al: Nephrol Dial Transpl 23/2010Richards N., et al: Nephrol Dial Transpl 24/2011
GFR ;13,1% 5% 1 27,7% 30,4% 4 5 GFR 60
Nephrol Dial Transplant (2010) 25: 28322836
Nephrol Dial Transplant (2010) 25: 28322836 ; combine all levels of eGFR with ACR measurements..
o Cores et al, JAMA,2011 . . . GFR 60-89 ml/min
. . .
. . . 75% >70 GFR
GFR Levey AS et al Kidney Int 2005;67:2089-00 2005 GFR..
Marker of Kidney DamageGFRCKDWhat to do?+60YAction Plan-60N
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End- StageProgressionInitiationAt Risk , , ( GFR) , Sarnak and Levey, Am J Kidney Dis 2000;35:S11731. ,
Seminars in Dialysis 23: 129133, 2010
http://www.cdc.gov/diabetes/pubs/estimatesNational Diabetes Fact Sheet 2011 27% > 65
9, NPHS1, HSPG2, SELL, CNDP1, LAMNA, ELMO1ACE, ANP, AGTAKR1B1, GFPT2, SLC2A1, GECCR5, IL1, IL6, IL1RN, TGFBR, RANTESAPOENOS3, ENPP1, MnSODPPARG, TSC22, PRKCB, BDKRB2P22phox, SLC12A3
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Skyller JS.,et al .Diabetes Care, 32,1 2009Intensive Glycemic Control and the Prevention of Cardiovascular Events:Implications of the ACCORD, ADVANCE, and VA Diabetes Trials
A position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart AssociationADA, C-level recommendation; ACC/AHA, level of evidence C
Perhaps we should call for future guidelines to be formulated in such a way that they would set various treatment targets and regimens for various groups of patients, depending on the stage of the disease they are at
for newly diagnosed and uncomplicated ones an HbA1c of
End- StageProgressionInitiationAt Risk , , ( GFR), , Sarnak and Levey, Am J Kidney Dis 2000;35:S11731. ,
ESH/ESC Guidelines J Hypertension 2007; 25:11051187
(%) - NHANES III Franklin SS, Jacobs M, Wong ND, et al. JACC. 2000; 35: 334A020406080100 ()8070-79
, K K 61
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N Engl J Med 2010; 362: 1575-1585 ACCORDthe intensive-therapy group had significantly higher rates of serious adverse events.. ,, .
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Journal of Hypertension 2009, 27:21212158
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American Journal of Kidney Diseases, Vol 49, No 2, Suppl 2 (February), 2007
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Nephrol Dial Transplant (2010) 25: 39773982 RAS
Physicians should remember that the most common cause of end-stage renal disease among elderly persons with preexisting CKD is acute kidney injury secondary to radiocontrast procedures, anti-inflammatory drugs, or worsening heart failure, not a gradual decrease consistent with the natural history of CKD itself. Use of RAS blockers in such patients puts them at increased risk for worsening CKD.Sarafidis PA & Bakris GL, Ann Intern Med 2009
Start low, go slowbut get there
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/ Ferrario CG: Geropharmacology: AACN Adv Crit Care 19:134149, 2008Ferrario CG: Geropharmacology: AACN Adv Crit Care 19: 2335, 2008
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The issue in treating elderly patients with kidney disease is not efficacy but safetyGolden Rule
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