Thursday, 3 June 2010

Aging and the kidney – podocyte biology in the elderly

I had to smile. No mention of the “d” word in the supplement of this title. It also brought to mind one of Sir William Ostler’s aphorisms “the good physician treats the disease; the great physician treats the patient who has the disease”.

Seriously, it is good that basic science researchers are focussing on renal function decline because it becomes more and more important as we start to understand its increasing prevalence with aging and its impact on the global health and physical function of older individuals. We are increasingly learning more about the biology of aging, mechanisms whereby chronic inflammation potentiates kidney aging and the interaction of the various drivers for kidney injury.

The elderly often have a range of comorbidities that makes the management of advanced kidney disease and renal replacement therapy more complex than in the young with single organ dysfunction or failure. We need good science to understand where we can potentially intervene, good medicine that includes patients and their families in shared decision making so necessary for the “right choice” and a model of service delivery that is in line with the wishes and aspirations of our elderly patients with comorbidities.

It is encouraging to read the reports of kidney transplantation and successful dialysis in the elderly. Even very old patients can be treated successfully by these techniques. Multiple comorbidity and cognitive impairment can be overcome by assistance; but we shouldn’t shy away from also exploring the conservative kidney care pathway. Increasingly, many who 10 or 15 years ago, we thought had terminal renal failure will survive often with a quality of life that’s as good or better than on dialysis for one or 2 years on conservative therapy before death from vascular comorbidity. The Royal College of General Practitioners’End of Life Care Strategy” that complements NHS Kidney Care’s “End of Life Care in Advanced Kidney Disease – a framework for implementation” adds to our understanding of this aspect of medicine.