Abstract
BackgroundGiven the aging of the population, nephrologists are ever more frequently assisting nonagenarians with acute kidney injury (AKI). The management of these patients presents unique characteristics, including bioethical dilemmas, such as the utilization of renal replacement therapy (RRT) at this extreme age.MethodsWe conducted a retrospective cohort study at a tertiary hospital. Over a 10-year period, 832 nonagenarians were hospitalized for two or more days. A random sample of 461 patients was obtained; 25 subjects were excluded due to lack of essential data. AKI was defined and staged according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.ResultsWe analyzed data from 436 patients, mean age 93.5 ± 3.3 years, 74.3% female; 76.4% required intensive care unit (ICU). The incidence of AKI was 45%. Length of hospital stay, ICU admission, vasopressors, and mechanical ventilation (MV) were independent predictors of AKI. Overall in-hospital mortality was 43.1%. Mortality was higher in the AKI compared to the no AKI group (66.8% vs. 23.8%, p < 0.001). Only 13 patients underwent RRT; all were critically ill, requiring vasopressors and 76.9% in MV. Mortality for this RRT group was 100% but not significantly higher than that observed in 26 non-RRT controls (96.1%, p = 1.0) obtained by proportional random sampling, matched by variables related to illness severity. In multivariable analysis, age, Charlson’s score, vasopressors, MV, and AKI – but not RRT – were independent predictors of mortality.ConclusionsAKI is common in hospitalized nonagenarians and carries a grave prognosis, especially in those who are critically iil. The use of RRT was not able to change the fatal prognosis of this subgroup of patients. Our data may help guide informed decisions about the utility of RRT in this scenario.
Highlights
Given the aging of the population, nephrologists are ever more frequently assisting nonagenarians with acute kidney injury (AKI)
The incidence of AKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria was 45% (Table 2); approximately half of the AKI episodes were classified as KDIGO stage 1 with the other half almost split between KDIGO stages 2 and 3
When we stratified by hospital sector, we found that nonagenarians who were admitted to the intensive care unit (ICU) had a significantly higher incidence of AKI compared to those who stayed in the wards (51.9% versus 22.3%, p < 0.001)
Summary
Given the aging of the population, nephrologists are ever more frequently assisting nonagenarians with acute kidney injury (AKI). The management of these patients presents unique characteristics, including bioethical dilemmas, such as the utilization of renal replacement therapy (RRT) at this extreme age. The very elderly have peculiarities that place them at increased risk for acute kidney injury (AKI). The literature on AKI in the very elderly is scarce; when caring for these patients, Nephrologists often have to extrapolate data obtained in studies of younger individuals. In 2005, the Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney), a multinational cohort of nearly 30.000 patients, showed that the mean age of patients with AKI was 67 years old [3]. Other factors such as co-existing chronic health conditions, polypharmacy and need for invasive procedures contribute to the increased incidence of AKI in the elderly
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