1. Geriatric Nephrology
& Hypertension
in the elderly
성균관 의과대학교
강북삼성병원 신장내과
이 규 백
2010, June/8

2. The biochemical composition, the physiological
capacity, the ability to maintain homeostasis
Vulnerability to disease processes or death
Aging

4. Age-friendly Health Care, WHO
2000 년 2050년, 노인 ~30%

5. 전염질환 감소, 만성병과 정신병 증가

6. 노인 만성병
의료비용
사회적인 책임

7. ,Downhill, Iatrogenic

10. • Fall
• Urinary incontinence
• Immobility
• Infectious process
• Oral, dental diseases
• Food and nutrition: Sarcopenia 5~13%
• Delirium
• Dementias: 고령-기억력 장애 15~45%
• Depression: 고령의 투석환자-45% 우울증
• DM, HTN, CKD, atherosclerosis
……
Geriatric syndrome

11. Geriatric Nephrology
Has Come of Age:
At Last, 2009 ASN

12. Geriatric Nephrology
1. The incidence of new patients with ESRD:
over the age of 65 yr 
-over 65 yr-old: double in next 20yr
-over 85 yr-old: 38% growth during the
1990s
-75 yr-old: average 3.5 chronic disease
2. CKD patients: most of whom are elderly
65-74 yr:~25%, 75-85 yr:~35%, 85+yr:~45%

13. The Coming Pandemic of CKD/ESKD
and the Aging Population
70대가 말기신부전 발병의 절정!

14. Geriatric Nephrology

15. Why Do We Need a Geriatric
Nephrology Curriculum?
• This older population will bring
their problems to the nephrologists.
• Dialysis patients rely on their
nephrologists for most of their care.
“신장내과 의사가 80% 문제 해결”
“의료 공급자를 단순화-비용, 부작용 줄임”

16. Drug Dosing and Renal Toxicity
in the Elderly Patient
고령환자에서 약물부작용: 3-10배
신장질환: 부작용 급증
인식, 감각,기억력

17. Drug in the Elderly Patient

18. Drug Dosing and Renal Toxicity
in the Elderly Patient
• Review patients past medical history and
medication: drug–drug interactions
• For GFR<50 ml/min: adjust drugs according to
the renal function
• Dosage modification: dose reduction, dosing
interval prolongation, or both methods
• Consider therapeutic drug monitoring (TDM)
in older patients with renal impairment
최소로 단순하게 약을 투여하여야!

19. Medication in the elderly

20. • Elderly patients: at higher risk for the AKI
• Hemodynamic, metabolic, and molecular
changes  increased susceptibility to
injury
• Multiple etiologies are often operative in
the development of AKI.
• The outlook for renal recovery is likely
impaired in the elderly patient. (단지 28%
회복률)
Acute Kidney Injury in the Elderly

21. Acute Kidney Injury in the Elderly

22. Decision Making
VES: Vulnerable Elders Survey, ADL: Activities of Daily Living
건강 취약 허약

23. • Healthy/usual(건강): might be a transplant
candidate
• Vulnerable(취약): typical dialysis candidate,
Geriatric assessment and intervention
plans may slow the progression of
geriatric susceptibility factors
• Frail(허약): should be considered for a
nondialytic treatment plan or a time-
limited dialysis trial. Final decisions will
hinge on patient preferences, QOL, and
contextual issues
ACOVE stage
(Assessing Care of Vulnerable Elders)

24. Dialysis patient disease trajectory
투석환자 사망률: 24%/년, 입원율 66%/년
80대, 90대 투석환자 사망률: 46%/년
삶의 궤적
이상적인 치료

25. The trajectory of care during chronic illness
임종, 존엄사, well-dying

26. Hypertension
in the Elderly

29. President FD Roosevelt dying of a cerebral hemorrhage on April 12,
1945, and his physician, AR McIntire, declaring that “it had come out
of the clear sky,” even though Roosevelt was known to have had
Hypertension and CRF for more than ten years.

31. “I’ve also been treating the
high cholesterol and then
I stopped the medicine
because I got my
cholesterol down low. And,
I had in the past, a little
blood pressure problem,
which I treated and then I
got it down…”
Former US President Clinton, awaiting coronary bypass surgery,
calls into Larry King Live from his hospital bed; Sept 3, 2004,
Non-adherence to treatment
Comorbidity, Life style

32. 대한임상노인의학회 2009

33. -associated with elevated cardiac output, such as
anemia, hyperthyroidism, aortic insufficiency, AV
fistula, and Paget’s disease of bone.
-most cases are caused by reduced elasticity and
compliance of large arteries resulting from age
and from the atherosclerosis-associated
accumulation of arterial calcium and collagen and
the degradation of arterial elastin.
Increasing PWV, raising the peak systolic BP.
Isolated systolic hypertension,
elderly hypertension

34. Mean Blood Pressure According to Age and
Race or Ethnic Group in U.S. Adults
NEJM 2007;357:789-796

35. Frequency of Untreated Hypertension
According to Subtype and Age
NEJM 2007;357:789-796

36. -When BP measurements are elevated,
but the BP is actually normal.
-As people get older, the walls of the
arteries sometimes get very thick, and
calcium may be deposited in the
arterial wall. This makes the arteries
very stiff and difficult to compress.
Pseudohypertension

37. Doctors usually suspect
pseudohypertension in cases where:
-The BP reading is very high over
time, but the patient has no signs
of organ damage or other Cx.
-Attempting to treat the measured
high BP causes symptoms of low BP
(dizziness, confusion, decreased UO)

38. The Osler maneuver is performed by palpating
the pulseless radial or brachial a. distal to the
point of occlusion of the a. by the sphygmo-
manometric cuff. When either of these a.
remains palpable (despite being pulseless), the
patient is described as “Osler positive.” In
contrast, when either a. collapses and becomes
impalpable, the patient is “Osler negative.”
Osler in 1892, Messerli et al in 1985
Nowadays, Inappropriate,
Upper limb PWV, Intraarterial BP
Osler’s maneuver

39. NEJM 1985;321:1548-1551

41. White Coat Hypertension

42. -Patients were 60 years old or more. Systolic BP was
160 mm Hg or greater and diastolic BP was less than
95 mm Hg.
-8 trials, 15,693 patients, were followed up for 3.8
years.
Active treatment reduced total mortality by 13% (95%
CI 2–22, p=0·02), cardiovascular mortality by 18%, all
cardiovascular complications by 26%, stroke by 30%,
and coronary events by 23%.
Lancet 2000; 355: 865–872

43. Lancet 2000; 355: 865–872

44. Summarised results in older patients with isolated systolic
hypertension enrolled in 8 trials of antihypertensive drug treatment
Lancet 2000; 355: 865–872
30%  23%  26%  13% 
N=15,963
F/U for 3.8yr

45. -Leiden, The Netherlands.
-599 inhabitants of the birth-cohort 1912–
1914 were enrolled on their 85th birthday.
There were no selection criteria related to
health or demographic characteristics.
The mean follow-up was 4.2 years.
During follow-up 290 participants died, 119
due to cardiovascular causes.
J Hypertension 2006, 24:287–292

46. Cumulative all-cause mortality depending on
systolic and diastolic BP at age 85 years.
N=599
F/U for 4.2 yr
J Hypertension 2006, 24:287–292

47. High BP at baseline (age 85 yr) was
not a risk factor for mortality.
Baseline BP values below 140/70
mmHg (n = 48) were associated
with excess mortality,
predominantly in participants with
a history of hypertension
Confounding poor health status!
pitfall of observation study
J Hypertension 2006, 24:287–292

48. Randomly assigned 3845 patients who were 80
years of age or older and had a sustained systolic
BP of 160 mm Hg or more to receive either the
diuretic indapamide (sustained release, 1.5 mg) or
matching placebo. The ACE inhibitor perindopril
(2 or 4 mg) was added if necessary to achieve the
target BP of 150/80 mm Hg.
N Engl J Med 2008;358:1887-98

49. N Engl J Med 2008;358:1887-98
Placebo
(1912 patients)
active-treatment
(1933 patients)
Median follow-up
=1.8 years.
Mean BP According to Study Group
HYVET Study: HTN in the very elderly trial(>80yr)

50. HYVET Study: HTN in the very elderly trial(>80yr)
N Engl J Med 2008;358:1887-98
N=3845, F/U=1.8 yr

51. NEJM 2007:357;789-796
Isolated Systolic Hypertension in the Elderly

52. NEJM 2007:357;789-796
Isolated Systolic Hypertension in the Elderly

53. Antihypertensive drugs
JNC 7, Five major classes: AABCD
ACE inhibitors, ARB, β-adrenergic blockers,
CCB, diuretics
ESH, ESC, British guideline
-no preference to diuretics
-argue against diuretics and β blockers
In two thirds of patients with hypertension,
two or more drugs will be required to
achieve target BP levels. “Combination
therapy”

54. Strategies for Improving BP Control
Fail to treat:
inadequate patient education, physician empathy,
and social support; the presence of coexisting
diseases; complex dose regimens; problems with
transportation of the patient, side effects and the
cost of medications.
Cooperation: physician, nurse clinicians,
physicians’ assistants, and pharmacists
A low starting dose and a gradual increase (e.g.,
every 2 to 4 weeks): in frail, immobile and
diabetes patients

55. Area of Uncertainty
-Clinical studies are not enough.
-Exact measurement of BP
-Pseudohypertension
-Old age?
Extreme old age(80 yr)
-Target BP? 150/80 mmHg
-Systolic BP: >160 mmHg
140-159 mmHg, no studies
-Subgroup analysis:
heart dz, DM, storke, CKD, not mobile pt

56. Summaries
Geriatric Nephrology
-Geriatrics; multiple pathology, polypharmacy
-Pandemic of CKD/ESKD; cardiovasc cx, infection,
multiple cx
-Adverse drug reaction
-AKI on CKD
Hypertension in the elderly
-misconception, non-adherence
-pseudoHTN, white coat HTN
-isolated hypertension
-HYVET study: sys BP>160  target BP 150/80 mmHg
-Subgroup?
-Target BP? Patient to patent, comorbidity, PseudoHTN