In PracticeManaging Older Adults With CKD: Individualized Versus Disease-Based Approaches
Section snippets
Case 1
A healthy 84-year-old man with mild hypertension and no other comorbid conditions had a glomerular filtration rate (GFR) of 70 mL/min/1.73 m2 (1.17 mL/s/1.73 m2) and no proteinuria. Over several weeks, his GFR decreased to 20 mL/min/1.73 m2 (0.33 mL/s/1.73 m2) and he was found to have proteinuria (2+) and red blood cell casts on urinalysis. On further testing, he had a protein-creatinine ratio of 2,000 mg/g and serologic workup was notable for the presence of a positive antineutrophil
Limitations of a Disease-Based Approach
The last decade has seen the evolution of a disease-based approach to chronic kidney disease (CKD) involving the development, dissemination, and refinement of practice guidelines for this condition (Fig 1).1 These guidelines have served a variety of different purposes that include establishment of a working definition of CKD, systematic review of available evidence, and formulation of treatment strategies and potential performance measures based on available evidence.5, 6, 7
Because
Individualized Patient-Centered Care
Given the limitations of disease-oriented models of care in older populations, geriatricians often favor a more individualized patient-centered approach. The individualized approach prioritizes patient goals and preferences and embraces the notion that observed signs and symptoms may not be the consequence of a single disease process, but instead reflect the complex interplay between a variety of different factors, including pathologic processes, aging, and social and psychological factors (
Disease-Oriented Versus Individualized Patient-Centered Care
Most older adults with CKD will fall somewhere between the 2 extreme cases presented earlier. Unlike the patient described in case 1, clinical presentation and treatment options are unlikely to be shaped by a single underlying pathophysiologic process and most will have competing health priorities and unique preferences. Nevertheless, many will derive some benefit from disease-based interventions, unlike the patient described in case 2. However, these interventions may be most beneficial if
Role of Prognostic Information in Individualized Patient-Centered Care
Although individualized treatment plans are driven by patient preferences and values, accurate prognostic information often is very helpful in crafting these plans. For example, treatment decisions for the patient described in case 3 may depend on her expected risk of progressive loss of kidney function with and without NSAID use. The extent to which the patient described in case 4 and his caregiver prioritize visits to the renal clinic may depend on his expected risk of progressing to
Conclusions
For many older adults who meet the criteria for CKD, an individualized patient-centered approach may have more to offer than the traditional disease-oriented approach. An important feature of the individualized approach is that it can always accommodate disease-based treatment strategies if these are aligned with patient goals and preferences. However, treatment strategies that are informed by only the presence and severity of abnormalities in kidney function (and associated risk information)
Acknowledgements
Support: Support was through a Beeson Career Development Award from the National Institute on Aging to Dr O'Hare and the Birmingham/Atlanta Geriatric Research Education and Clinical Center Special Fellowship in Advanced Geriatrics and John A. Hartford Foundation/Southeast Center of Excellence in Geriatric Medicine to Dr Bowling.
Financial Disclosure: The authors declare that they have no relevant financial interests.
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Originally published online December 22, 2011.