Pam Harrison

May 27, 2016

VIENNA — The increasing demand for nephrology services by the aging population in Europe makes the management of chronic kidney disease a challenge, but a first-of-its-kind initiative could help nephrologists take control of the impending surge.

In the SCOPE project, European nephrologists are joining forces with their colleagues in the field of geriatrics to better identify, characterize, and anticipate the consequences of kidney disease in patients 75 years and older, experts reported here at the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) 53rd Congress.

For the observational, prospective cohort study, 2450 patients who present to outpatient clinics in seven European countries will be invited to participate.

The goal is "to assess the impact of kidney disease in older multimorbid patients, not only from a nephrology standpoint, but also in terms of what's happening to patients' functionality and health-related quality of life, along with the social, economic, and public health impact this disease has on elderly patients," Regina Roller-Wirnsberger, MD, professor of geriatrics at the Medical University of Graz in Austria, told reporters attending a news conference.

SCOPE "is the first project I am aware of in which geriatricians and nephrologists will work together for a common goal," she added.

"The elderly have diabetes, they have vascular disease, and it doesn't matter if they have acute or chronic kidney disease, the proportion of patients over the age of 60 and 70 who are coming to our clinics with impaired kidney function is growing," said Danilo Fliser, MD, from Saarland University Medical Centre in Homburg, Germany, who is chair of the ERA-EDTA scientific committee.

One of the primary objectives of the project is to ascertain whether standard screening methods, such as those now used to estimate filtration rates in the kidney, are actually helpful in identifying kidney disease in the elderly. Current creatinine-derived screening methods are not accurate in older patients, said Andrea Corsonell, MD, director of the geriatric pharmacoepidemiology unit at the INRCA Research Hospital in Cosenza, Italy.

"Age-related chronic diseases are associated with loss of muscle mass, and loss of muscle mass means less creatinine is produced," Dr Corsonell explained.

In the SCOPE project, estimated glomerular filtration rate (eGFR) will be assessed in geriatric patients with an equation developed in the Berlin Initiative Study specifically for people older than 70 years (Eur J Epidemiol. 2010;25:203-210).

eGFR measured with the Berlin equation will be a more accurate gauge of the functional status of the kidney, at least in an elderly population, the speakers at the meeting agreed.

The rate of kidney function decline ascertained with the equation "will be compared with that estimated by novel biomarkers, such as cystatin C, beta₂ microglobulin, and beta-trace protein," Dr Corsonell explained.

"The search for potentially new biomarkers of kidney function in this patient population is very important," she added.

The problem we have now with chronic kidney disease is similar to the problem we had with blood pressure 10 or 15 years ago.

"The problem we have now with chronic kidney disease is similar to the problem we had with blood pressure 10 or 15 years ago," said Carmine Zoccali, MD, from the clinical epidemiology of renal diseases and hypertension unit at the National Research Council in Reggio Calabria, Italy, who is president-elect of the ERA-EDTA.

As little as a decade ago, the treatment of high blood pressure in the elderly was considered irrelevant; hypertension was seen as an "almost innocent risk factor," he explained.

"Now there is super solid evidence that appropriately treated hypertension in the old prevents strokes, disability, and certain cases of heart failure, so the degree of risk reduction with the appropriate treatment of high blood pressure in the old is not trivial at all," Dr Zoccali said.

There is controversy among some nephrologists about whether kidney disease is actually a disease at all, at least in the elderly.

But "in Italy, we are convinced that chronic kidney disease is a disease in the old," Dr Zoccali said.

In one long-term follow-up study, there was a 70% excess mortality risk in a cohort of Italian patients older than 65 years with mild renal impairment, he reported. This risk was independent of other confounding variables, a sign that even mild kidney problems are far from benign.

"So this pan-European study is very important. We need European information, and SCOPE is designed to gather new information on the diagnosis and the prognosis of kidney disease in the very old," said Dr Zoccali.

Approximately 20% of the population of Italy is older than 75, and one in three people older than 75 has kidney disease, he added.

Not Just Nephrology

Although one aspect of the SCOPE project is nephrology, it is not the sole focus. What is happening in other life domains in elderly patients with kidney disease is equally important.

"What we as geriatricians see in those with declining kidney function is a clear association with functional decline," Dr Roller-Wirnsberger said.

In a multimorbid population where kidney disease serves as a kind of "morbidity promoter," there is often a corresponding decline in overall functional capacity and a patient's ability to cope with the activities of daily life, she added.

To better assess the overall impact of kidney disease on the elderly, SCOPE participants will undergo a comprehensive geriatric assessment that includes mobility, such as walk speed, which is a good measure of how well a kidney patient is functioning.

We will try to get the whole picture.

The presence of depressive symptoms — extremely common in kidney disease patients — will also be assessed, as will nutritional and cognitive status.

"We will try to get the whole picture," said Dr Roller-Wirnsberger.

"And we want to see whether we can cluster patients with certain risk profiles together to identify those who are especially prone to develop deficits during their journey through chronic kidney disease," she explained.

It was the geriatricians — not the nephrologists — who initiated the SCOPE project earlier this year, said Alexander Rosenkranz, MD, head of the division of nephrology at the Medical University of Graz.

"Nephrologists are more biomarker-driven. We look at creatinine, we look at proteinuria, we're experts in vitamin D metabolism, but we don't look at the functionality of our patients, or what functionality might even mean for an older patient with chronic kidney disease," he said.

"The SCOPE project is a combined effort between two groups of specialists, and we have much to learn from each other," Dr Rosenkranz added.

European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) 53rd Congress. Presented May 22, 2016.


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