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Age Affects Outcomes in Chronic Kidney Disease

Ann M. O'Hare^*, Andy I. Choi, Daniel Bertenthal, Peter Bacchetti, Amit X. Garg^||, James S. Kaufman^¶, Louise C. Walter, Kala M. Mehta, Michael A. Steinman, Michael Allon^**, William M. McClellan and C. Seth Landefeld

^* Department of Medicine, VA Puget Sound Healthcare System and University of Washington, Seattle, Washington; Department of Medicine, VA Medical Center San Francisco, and University of California, San Francisco, VA San Francisco Health Services Research and Development Research Enhancement Award Program, VA San Francisco, and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; ^|| Division of Nephrology, University of Western Ontario, London, Ontario, Canada; ^¶ Renal Section, VA Boston Healthcare System, Boston, Massachusetts; ^** Division of Nephrology, University of Alabama at Birmingham; and Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia

Correspondence: Dr. Ann M. O'Hare, Department of Medicine, University of Washington, VA Puget Sound Healthcare System, Division of Nephrology, Building 100 Room 5B113, 1660 S. Columbian Way, Seattle, WA 98108. Phone: 206-277-3192; Fax: 206-764-2022; E-mail: ann.ohare{at}va.gov or amoh{at}u.washington.edu

Received for publication April 6, 2007. Accepted for publication July 9, 2007.

Chronic kidney disease (CKD) is common among the elderly. However, little is known about how the clinical implications of CKD vary with age. We examined the age-specific incidence of death, treated end-stage renal disease (ESRD), and change in estimated glomerular filtration rate (eGFR) among 209,622 US veterans with CKD stages 3 to 5 followed for a mean of 3.2 years. Patients aged 75 years or older at baseline comprised 47% of the overall cohort and accounted for 28% of the 9227 cases of ESRD that occurred during follow-up. Among patients of all ages, rates of both death and ESRD were inversely related to eGFR at baseline. However, among those with comparable levels of eGFR, older patients had higher rates of death and lower rates of ESRD than younger patients. Consequently, the level of eGFR below which the risk of ESRD exceeded the risk of death varied by age, ranging from 45 ml/min per 1.73 m² for 18 to 44 year old patients to 15 ml/min per 1.73 m² for 65 to 84 year old patients. Among those 85 years or older, the risk of death always exceeded the risk of ESRD in this cohort. Among patients with eGFR levels <45 ml/min per 1.73 m² at baseline, older patients were less likely than their younger counterparts to experience an annual decline in eGFR of >3 ml/min per 1.73 m². In conclusion, age is a major effect modifier among patients with an eGFR of <60 ml/min per 1.73 m², challenging us to move beyond a uniform stage-based approach to managing CKD.

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