Understanding outcomes and improving research methodologies for older patients with chronic kidney disease

Abstract

Background: Chronic kidney disease (CKD) prevalence among older individuals has dramatically increased. There is a need to slow progression to kidney failure, align treatments with patient preferences, and support shared decision-making for older patients. Methods: Chapter 2 reports on the Elderly Advanced CKD Program, a program enrolling patients ≥75 years with kidney failure. Chapter 3 reviews waiver of consent in low-risk research, a consent model used in the Elderly Advanced CKD Program. Chapter 4 compares patients enrolled in the OUTcomes of Older patients with Kidney failure (OUTLOOK) study, the main component of the Elderly Advanced CKD Program, with incident kidney replacement therapy (KRT) patients ≥75 years in the ANZDATA Registry. CKD risk prediction models in older patients are reviewed in Chapter 5. Chapters 6 and 7 evaluate SGLT2 inhibitors in older patients. Chapter 8 estimates a minimal important difference (MID) for the EQ-5D-5L utility index in dialysis patients. Results: The Elderly Advanced CKD Program is enrolling patients at 8 Australian sites, and comparison with incident KRT patients ≥75 years in ANZDATA indicates an older, comorbid, largely community-dwelling cohort, with a high proportion choosing conservative kidney management. Review of CKD risk prediction models in older patients indicates combined use of the Kidney Failure Risk Equation (KFRE) and Mortality Risk Equation for Kidney disease (MREK) holds highest clinical utility. Pooled analysis from the CANVAS Program and CREDENCE trial, and meta-analysis of SGLT2 inhibitor trials indicate cardiorenal benefits extend across the spectrum of age and frailty. MID estimates for the EQ-5D-5L utility index in dialysis patients range from 0.034-0.134. Conclusions: This thesis identifies that high-quality studies involving older CKD patients are feasible and essential in generating evidence to guide older patients, carers and clinicians as they make life-impacting CKD treatment decisions.