Targeting Nephrology Referral Among Elderly Patients with Chronic Kidney Disease

描述(由申请人提供)：这项申请的指导原则是，老年人慢性病的管理必须包括老年人口的相当大的异质性，并且必须基于对哪些老年患者最有可能进展为症状性疾病的理解。慢性肾脏病(CKD)是老年人的常见疾病，老年是CKD患者死亡和进展为终末期肾病(ESRD)的危险因素。然而，几乎没有数据来指导老年人慢性肾脏病的治疗。这项拟议的研究的核心问题是，应该如何在老年患者中管理CKD。这里提出的研究议程将集中在老年人透析前规划的具体领域。在最终发展为终末期肾病的患者中，早期干预为透析做准备与较好的结果和较少的透析开始后的并发症有关。因此，目前建议患者在发生严重的慢性肾功能不全或在终末期肾病发作前一年左右时，应转诊至肾病专科医生，以便为透析做准备。由于与慢性肾脏病相关的不良结局和开始透析的老年患者透析前肾脏病转诊率低，越来越多的人支持干预措施，以提高初级保健提供者的肾脏病转诊和慢性肾脏病意识。然而，在很大程度上由于老年人死亡的巨大竞争风险，即使是严重的CKD患者死亡的可能性也比进展为ESRD的可能性要大得多。因此，在患有严重慢性肾脏病的老年患者中增加肾脏病转诊的广泛努力可能会对不需要透析的患者造成潜在的伤害(例如，不必要的血管通路放置和诊所就诊)。为了确定如何更好地将肾脏病转诊到那些最有可能进展为终末期肾病的老年患者，我们将：1)在患有严重CKD的全国退伍军人队列中检查ESRD短期发病的预测因素，2)确定同一队列中进展为ESRD风险最高的老年患者“转诊中”的预测因素，以及3)招募75岁及以上的中重度CKD患者，以确定是否：1)使用胱抑素C(一种新的肾功能测量方法)，2)简单的“床边”功能状态评估可以提高我们识别最有可能存活到ESRD的晚期CKD老年患者的能力。

DESCRIPTION (provided by applicant): The guiding principle for this application is that the management of chronic diseases in the elderly must embrace the considerable heterogeneity of the elderly population and must be based on an understanding of which older patients are most likely to progress to symptomatic disease. Chronic kidney disease (CKD) is a common condition in the elderly and older age is a risk factor both for death and for progression to end-stage renal disease (ESRD) among patients with CKD. However, few data exist to guide management of CKD in the elderly. The central question underlying the proposed research is how CKD should be managed in older patients. The research agenda proposed here will focus on the specific area of pre-dialysis planning in the elderly. Among those who ultimately develop ESRD, early intervention to prepare for dialysis is associated with better outcomes and fewer complications after initiation of dialysis. Therefore, it is currently recommended that patients be referred to a nephrologist for preparation for dialysis when they develop severe CKD or approximately one year before onset of ESRD. Because of poor outcomes associated with CKD and low pre-dialysis nephrology referral rates in elderly patients beginning dialysis, there is growing support for interventions to increase nephrology referral and CKD awareness among primary care providers. However, due in large part to the substantial competing risk of death in the elderly, even patients with severe CKD are much more likely to die than to progress to ESRD. Thus, broad efforts to increase nephrology referral among elderly patients with severe CKD may result in potential harm (e.g. unnecessary vascular access placement and clinic visits) in patients unlikely to require dialysis. To identify ways to improve targeting of nephrology referral to those elderly patients most likely to progress to ESRD we will: 1) examine predictors of short-term onset of ESRD in a national cohort of elderly veterans with severe CKD, 2) identify predictors of "under referral" of elderly patients at highest risk for progression to ESRD in the same cohort, and, 3) recruit a cohort of patients 75 years and older with moderate to severe CKD in order to determine whether: 1) use of cystatin C (a novel measure of renal function), and 2) simple "bedside" assessment of functional status can improve our ability to identify those elderly patients with advanced CKD most likely to survive to ESRD.