Targeting Nephrology Referral Among Elderly Patients with Chronic Kidney Disease

描述（由申请人提供）：本申请的指导原则是，老年慢性病的管理必须考虑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。慢性肾脏疾病（CKD）是老年人的常见病，高龄是CKD患者死亡和进展为终末期肾脏疾病（ESRD）的危险因素。然而，很少有数据可以指导老年CKD的管理。提出的研究的核心问题是如何管理老年患者的慢性肾病。这里提出的研究议程将集中在老年人透析前计划的具体领域。在最终发展为ESRD的患者中，早期干预以准备透析与开始透析后更好的预后和更少的并发症相关。因此，目前建议患者在发生严重CKD或ESRD发病前一年左右转介到肾病科进行透析准备。由于CKD预后不佳，且开始透析的老年患者透析前肾病转诊率较低，因此越来越多的人支持干预措施，以增加初级保健提供者的肾病转诊和CKD意识。然而，在很大程度上，由于老年人存在大量的竞争死亡风险，即使是严重CKD患者死亡的可能性也比进展为ESRD的可能性大得多。因此，在老年严重CKD患者中增加肾病转诊的广泛努力可能会对不太可能需要透析的患者造成潜在危害（例如，不必要的血管通路放置和门诊就诊）。为了确定如何提高那些最有可能进展为ESRD的老年患者的肾内科转诊的针对性，我们将：1)在患有严重CKD的老年退伍军人国家队列中检查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的“未转诊”预测因素，以及3)招募75岁及以上的中重度CKD患者队列，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那些最有可能存活到ESRD的老年晚期CKD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.