Trajectories of Kidney Dysfunction in Older Adults with Chronic Kidney Disease

患有慢性肾病的老年人肾功能障碍的轨迹

• 批准号: 8541528
• 负责人: Christopher Barrett Bowling
• 金额: --
• 依托单位: BIRMINGHAM VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-07-01 至 2018-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8541528
• 关键词: Activities of Daily Living; Acute; Address; Admission activity; Adult; Age; Cardiovascular Diseases; Cessation of life; Chronic; Chronic Kidney Failure; Complex; Data; Development; Diabetes Mellitus; Diagnosis; Disease; Disease Association; Disease Outcome; Dose; Elderly; End stage renal failure; Event; Family; Functional disorder; Future; Glomerular Filtration Rate; Goals; Health; Health Status; Heart Diseases; Heterogeneity; Hospitalization; Hypertension; Impaired cognition; Infection; Information Technology; Intercept; Intervention; Kidney; Kidney Diseases; Knowledge; Lead; Measures; Mental Health; Methods; Mind; Modeling; Nephrotoxic; Nursing Homes; Organ; Outcome; Patient-Focused Outcomes; Patients; Pattern; Pharmaceutical Preparations; Population; Precipitating Factors; Predisposing Factor; Prevalence; Problem Solving; Provider; Renal function; Reporting; Research; Risk; Role; Sampling; Self Management; Shapes; Signs and Symptoms; Statistical Methods; Structure; Survival Analysis; Techniques; Time; Uncertainty; Veterans; Work; adverse outcome; austin; base; body system; burden of illness; cohort; design; disability; frailty; functional decline; high risk; human very old age (85+); innovation; mortality; patient oriented; preference; prevent; prospective; public health relevance; shared decision making

DESCRIPTION (provided by applicant): In the VA population, the prevalence of chronic kidney disease (CKD), defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2, increases from <5% among adults 18-44 years old to nearly 50% among those >85 years old. CKD is associated with many adverse outcomes including the development of end-stage renal disease (ESRD) as well as higher rates of mortality, cardiovascular disease (CVD), CKD- related complications and functional decline. While the presence of abnormalities in kidney function in older Veterans with CKD are clearly associated with adverse health outcomes, many of these patients have multiple co-morbid conditions and diminished functional reserve across a range of organ systems. The prevalence of hypertension, diabetes, and CVD and the burden of frailty and disability are substantial in older adults with CKD. In the geriatric population, the presence of these other conditions may diminish the value of a purely disease-oriented approach that focuses only on the role of intrinsic kidney abnormalities in understanding trajectories of kidney function. In contrast, an individualized, patient-centered approach prioritizes patient goals and preferences and recognizes that observed signs and symptoms in older adults are often multi-factorial reflecting the complex interplay between one or more chronic predisposing and acute precipitating events. With this in mind, we propose an incremental research agenda to better understand the predictors, outcomes and significance of different longitudinal trajectories of kidney function in older Veterans. Only a few prior studies have evaluated longitudinal trajectories of kidney function. These studies demonstrate that there is substantial heterogeneity in kidney function trajectories in patients with CKD and that many patients follow a non-linear disease trajectory. Furthermore, qualitative work has suggested that uncertainty about the expected course of CKD appears to be an important concern among both patients and providers. In Aim 1, we will identify long- term predisposing factors and short-term precipitating factors associated with a decline in eGFR trajectory among older Veterans with CKD using multilevel change regression models. In addition to traditional measures of kidney disease burden, we will evaluate a range of time-varying factors of special relevance to older adults such as use and dosing of medications and intercurrent health events such as acute illness and hospitalization. In Aim 2, we will evaluate the association of different eGFR trajectories with both traditional CKD outcomes and nontraditional, patient-centered outcomes of relevance to older adults with CKD (e.g., nursing home admission). Finally, in Aim 3, we will examine how older Veterans view and prioritize challenges related to CKD self-management at specific points along different eGFR trajectories using the nominal group technique (NGT). Knowledge of these barriers will allow us to better engage patients in shared-decision making and problem solving strategies as well as design patient- and family-centered interventions directly targeting these barriers. Older adults are particularly vulnerable to changes in health status or acute insults. However, prior studies have not addressed how dynamic changes in the health of older CKD patients impact eGFR trajectory. Further we do not know the significance of eGFR trajectory from the patient's perspective. To fill these knowledge gaps we propose a comprehensive approach using both advanced statistical methods and an innovative qualitative component that will identify (1) time-varying and event-based factors associated with a decline in eGFR trajectory, (2) patient-centered outcomes associated with eGFR trajectory, and (3) patient-reported barriers to CKD self-management at specific points in eGFR trajectory.

描述（由申请人提供）： 在VA人群中，慢性肾脏疾病（CKD）的患病率定义为估计的肾小球滤过率（EGFR）<60 mL/min/min/1.73 m2，在18-44岁的成年人中的<5％增加到> 85岁> 85岁的成年人的近50％。 CKD与许多不良后果有关，包括终末期肾脏疾病（ESRD）以及较高的死亡率，心血管疾病（CVD），CKD相关并发症和功能下降。尽管CKD老年退伍军人的肾脏功能异常显然与不利的健康结果有关，但其中许多患者的合并状况有多种疾病，并且在一系列器官系统中的功能储备减少。高血压，糖尿病和CVD的患病率以及CKD老年人的脆弱和残疾负担很大。在老年人群中，这些其他条件的存在可能会降低纯粹面向疾病的方法的价值，该方法仅着眼于内在肾脏异常在理解肾脏功能轨迹中的作用。相比之下，一种个性化的，以患者为中心的方法优先考虑患者的目标和偏好，并认识到老年人观察到的体征和症状通常是多因素的，反映出一个或多个慢性易感性和急性沉淀事件之间的复杂相互作用。考虑到这一点，我们提出了一个增量的研究议程，以更好地了解肾脏功能在老年退伍军人中不同纵向轨迹的预测因素，结果和意义。只有少数几项研究评估了肾功能的纵向轨迹。这些研究表明，CKD患者的肾功能轨迹存在很大的异质性，许多患者遵循非线性疾病轨迹。此外，定性工作表明，CKD预期过程的不确定性似乎是患者和提供者的重要问题。在AIM 1中，我们将使用多级变化回归模型来确定与EGFR轨迹下降有关的长期诱发因素和与EGFR轨迹下降相关的短期降水因素。除了传统的肾脏疾病负担措施外，我们还将评估一系列与老年人的特殊相关因素的范围，例如使用和剂量药物以及诸如急性疾病和住院治疗之类的健康事件。在AIM 2中，我们将评估不同的EGFR轨迹与传统的CKD结局和与CKD老年人相关的非传统的，以患者为中心的结果（例如疗养院入院）的关联。最后，在AIM 3中，我们将研究年长的退伍军人如何使用名义组技术（NGT）在不同EGFR轨迹的特定点上对CKD自我管理相关的挑战。对这些障碍的了解将使我们能够更好地吸引患者参与共享决策和解决问题的策略，并设计以患者和家庭为中心的干预措施，直接针对这些障碍。老年人特别容易受到健康状况变化或急性侮辱的影响。但是，先前的研究尚未解决老年CKD患者健康的动态变化如何影响EGFR轨迹。此外，我们从患者的角度不知道EGFR轨迹的重要性。为了填补这些知识空白，我们提出了一种使用先进的统计方法和创新的定性组件提出的全面方法，该方法将确定（1）与EGFR轨迹下降相关的时变和基于事件的因素，（2）与EGFR轨迹相关的以患者为中心的结果，以及（3）EGFRAFFREFFREFFROFFROFER的CKD自我管理的患者重新培训的障碍。