Managing Kidney Health in Older Adults – Age vs Frailty

The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).

In this episode of For Kidneys Sake, consultants Prof Jeremy Levy and Dr Andrew Frankel are joined by Dr Melanie Dani, a geriatrician, to discuss the complexities of managing chronic kidney disease (CKD) in older adults. They highlight the importance of distinguishing between chronological age and frailty, two overlapping but distinct concepts that significantly influence clinical decision-making. The conversation explores how kidney function naturally declines with age, and raises the critical question of when this becomes a pathological concern requiring medical intervention.

Dr Dani stresses the value of personalised care, reminding listeners that older adults are not a homogenous group. Whether someone is a fit 85-year-old playing tennis or a frail resident in a care home, their values, priorities and tolerance for medical treatment will differ. The episode encourages shared decision-making, consideration of overall health context, and careful use of medications like ACE inhibitors and SGLT2 inhibitors based on likely benefits and side effects, rather than age alone.

Three Key Takeaways

1. Ageing vs Frailty: Frailty is a better predictor of health outcomes than age alone. It’s essential to assess a patient’s overall vulnerability and resilience when managing CKD.
2. Reduced GFR in Older Adults: A declining GFR may reflect normal ageing rather than disease, but it still carries risks, particularly cardiovascular. Management should be tailored to the individual, not solely guided by guidelines.
3. Personalised, Contextualised Care: Decisions about referral, investigation and treatment must consider the whole person—their wishes, comorbidities, and quality of life—rather than focusing only on kidney function metrics.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub

Transcript

Jeremy Levy

So hello again, I'm Jeremy Levy. I'm a consultant nephrologist at Imperial Healthcare.

Andrew Frankel

Hello, and I'm Andrew Frankel, a colleague of Jeremy's, also a consultant nephrologist working at Imperial College Healthcare NHS Trust.

Jeremy Levy

And you may know we've had a short break. I hope you're all enjoying the episodes we've released. And we're to be widening the topics now and talking about a whole variety of new areas, but of course, all things kidney-related. And if you're new to this, you might realise that our old podcasts were called The Rest is Kidneys, and now we're For Kidneys Sake! Great new title for our series of podcasts.

And in this episode, we're going to start to talk about the challenges of managing chronic kidney disease, CKD, in older people. Because we get lots of questions about this:  When are kidneys old? When is there disease? And about older people who are frail or healthy, and how we should manage these. And it's a really quite complex area.

Andrew Frankel

So it's a real pleasure today to be joined by Dr Mel Dhani, who's a consultant geriatrician who works very closely with the kidney team at Imperial, helping us with our increasing number of older people with kidney disease. Welcome Mel.

Melanie Dani

Thanks so much, Andrew and Jeremy. I am absolutely delighted to join you today in this conversation.

Jeremy Levy

We get loads of questions from GPs and practice nurses, and pharmacists about this sort of topic, and about chronic kidney disease management, and whether it needs to be adjusted for older people, or we should manage it in exactly the same way as for younger folks.

Melanie Dani

That's right, Jeremy, and thank you for connecting these two different topics. So there's being older and being frail. And these two are related, but actually different. Being older or elderly refers to advanced age, while frailty refers to increased vulnerability to adverse outcomes. We know that frailty is associated with advanced age and is associated with the physiological decline of multiple systems. But we have to remember that you can get young people who are frail, and much older people who are very fit.

We know that frailty is a better predictor of outcomes than age alone. And one of the defining features of frailty is the vulnerability to stressors. So, for frail patients, stressors can be something as minor as starting a new medication, spending a day in a GP waiting room, or waiting for hospital transport. So knowing someone's vulnerability, and this could just be the frailty score, is often a key factor in clinical decision making.

Jeremy Levy

That's a really important start, isn't it, separating frailty from age per se.

And Andrew, Mel mentioned sort of aging and frailty. What does that mean, do think, for kidneys? Do kidneys age? Do they get old?

Andrew Frankel

So Jeremy, whilst I would like to think I am not old, the reality is... 

Jeremy Levy

Andrew, I think you are.

Hehehehehe

Andrew Frankel

We are contemporaries Jeremy, I will say that. The reality is that kidney ageing starts from a relatively young age. We start noticing an EGFR decline from the age of 35.

And that EGFR will decline from normal physiological aging by about 0.3 to 0.5 ml per minute per year. And then after the age of 70, that rate of decline may increase. There is some variation between individuals in the rate of decline. It will be higher in people who start out with poor kidney function or lower GFR, those who have poorly controlled blood pressure, or those who have albuminuria.

So a 40-year-old with a GFR of about 70 will inevitably reach a GFR of about 55 by 70. Therefore, a low GFR of less than 30 in the very elderly is not uncommon.

Jeremy Levy

So this is a really important point, Andrew. So we are all losing kidney function as we age. And that then is the challenge, isn't it? Is there disease or not? Which is what we're going to talk about a bit later. And we should come to the very low GFRs in a moment because that's a slightly different topic. But there's this huge controversy, isn't there? If, for example, you're 80 years old and you've got a GFR of 55 and you've already intimated that that might not be uncommon, is that normal for your age or is that a disease?

Is it chronic kidney disease at all? And all the coding that we're banging on about with GPs, which is so important for recognizing health recognizing management, none of it includes age in per se, other than the fact of course, that the GFR formula has age in it. So anyone with a GFR 55, is this CKD? Should we be labeling this as CKD G3A? 

For me personally, an 80-year-old with a GFR of 55, I don't think this is a disease. I think this is older kidneys, but it is still useful, isn't it, to remind healthcare professionals that this is slightly reduced kidney function, and it's not absolutely normal. So, therefore, they should be careful prescribing anti-inflammatory painkillers, NSAIDs and other medicines and how they tackle patients, even though this might not be a disease itself. And I know you'll want to comment on that as well.

And that we should really think about, shouldn't we, before we move on to very old people with GFRs that are much lower, let's say 35.

Andrew Frankel

So I think I do agree with you, Jeremy. There is a nuance here. As you've said, there's a temptation to consider the reduced GFR in the elderly as a normal physiological variant. When one considers whether someone has a disease, what one wants to know is whether that abnormality that you've identified is associated with adverse outcomes. 

What we do know is that an individual with a GFR that is reduced, however old they are, carries with them all the potential risks that you find with that abnormality even if it's present in a younger person with an equivalent EGFR and CKD stage. This includes the fact that they will have an increased risk of cardiovascular disease, increased risk of poor medication excretion and an increased risk of propensity to advance in relation to CKD progression. And therefore, you do need to acknowledge the reduced EGFR when you are considering individuals' medicine management plan.

Jeremy Levy

I think that's really important, actually, and I was a little bit too blasé, probably, wasn't I? Yes, ageing kidneys have reduced EGFR, and that may simply be a result of ageing, but it's still very important to understand that this is associated with increased health risks and potentially poorer outcomes. But then we need to know, how do we think of that in the proper confines of older people? Which is where Mel's going to tell us to behave ourselves.

Melanie Dani

Yeah, and I really want to come in now, Jeremy and Andrew, because this is a very kidney-centric conversation. And we have to remember that kidneys sit inside a person who has a lot of other things to think about and deal with. Patients, particularly as they get older, may have other medical problems which may dominate their lives more, for example, heart failure, dementia or frailty. And these are critical considerations, and sometimes generic guidelines aren't so helpful. 

And the other thing to mention is that the elderly, or older people, and the frail, are absolutely not a homogeneous group of people and it's critical for us as clinicians to know why we're treating someone. For example, if we have a 75-year-old who's still working as a judge and completes half marathons, it's likely they're going to want to slow down any decline in their EGFR and avoid cardiovascular complications. On the other hand, for a 75-year-old who lives in a nursing home and maybe has COPD or heart failure or dementia, slowing down the GFR decline is likely to have very little significance to them.

And they're likely to have views on how many tests and tablets they can tolerate, and how they can have good control of their physical symptoms and perhaps focus on things like the quality of life. So it seems very obvious, but it's so crucial at the outset to know the values, wishes and priorities of the person sitting in front of us.

Jeremy Levy

That's really important, Mel, isn't it? And easily forgotten by us, sitting in secondary care. 

But also when we haven't got the patient in front of us. Very often, we're dealing with these as virtual referrals or looking at patients' records, but without seeing the person in front of us. 

So I want to ask both of you, Mel and Andrew, do you think, therefore, there should be any difference in the referral criteria of a person seen in primary care who's, say, let's say 80 years old? And they're known to have chronic kidney disease with let's say a GFR of 40. Is there any difference between an 80-year-old and a 50-year-old? And Andrew should kick off, and then we'll hand over to Mel.

Andrew Frankel

So Jeremy, a really important question because there are a lot of these people out there. When you're making the referral, there are a number of key issues that determine the reasoning behind the referral to secondary care in a patient with CKD.

This would include ensuring that there is no need to undertake more, I use the word sophisticated investigations, where the diagnosis is uncertain, such as kidney biopsy and so forth. Then, to ensure that medical optimisation is undertaken, and in some individuals, it is to plan for end-stage kidney failure management.

When considering the underlying diagnosis, the same approach that one takes for younger patients is reasonable, other than one will want to put that in the context of that individual, and you may want to temper the list of investigation one undertakes in the very frail. I was going to say very old or very frail. 

You need to consider in that 75 year old that Mel described in a nursing home: What would the diagnosis of myeloma actually add to that person's long-term management?

And where there is a significant difference, however, is related to the fact that many individuals with impaired kidney function who are over 80 are actually unlikely to reach end-stage kidney failure in their lifetime. So if you're not going to offer them a diagnostic benefit or a long term benefit in relation to renal outcome, you may not necessarily be giving them any advantage by getting them seen in a secondary care setting.

Now I want to add just one other thing. We have to move away from 20th century concepts of care only being delivered by either in primary care, or through a letter to secondary care for a secondary care consultation, to a situation where secondary care can advise primary care in a whole range of other ways: e-advice, virtual consultations and so forth. And I think that may make things a little easier in terms of managing this. I don't know, Mel, if you agree with anything I've said, or if you have any other thoughts on this.

Melanie Dani

Absolutely, Andrew. And that's a really good point that you've just made because often the clinician who knows the patient best, the GP, is best placed to understand their values and the context of their illness to their overall life. And it's also worth saying that even if somebody who is, say 80 or 85 with end stage kidney disease, comes to the renal clinic; even the treatments there are not always clear cut, particularly if they have frailty.

We know from retrospective observational data that dialysis, for example, is not necessarily the answer for all patients who are older or those  who have frailty, for example, in terms of prolonging or improving the quality of life. And that's why it's so essential to know what that person's values are, and to talk to them honestly about the proposed advantages and side effects of treatment so that we can really do shared decision making at every step.

Jeremy Levy

That's been really helpful both of you in terms of just thinking about older people, frail people, and the value of making diagnosis and when we should sort of think about referral. Because I think that this whole discussion, as Andrew alluded very well, that is sort of over simplistic, this referral or not. It's thinking about whether making a diagnosis is going to be helpful and therefore whether we can stop progression or whether sometimes we do need to plan for end-stage renal failure, which is not the majority of people.

The majority of older people are never going to reach the need for consideration of dialysis. For most of these people, it's managing risks and particularly cardiovascular risks that we talked about a lot in previous episodes. And of course, in primary care, GPs, and practice nurses, and pharmacists are very good about managing cardiovascular risk. And for much of chronic kidney disease, that is what we're talking about, minimizing cardiovascular risk, and the risk of strokes and heart attacks. And in a way, the progression of kidney disease is the least important thing. 

So let's get back to our older person, an 80-year-old, let's say, and they've got declining GFR and you've got a decline with no other markers such as proteinuria or hematuria. And you think that this is just a declining kidney function that might be aging, but it's abnormal. We would mostly say that almost certainly a referral isn't needed, and this is about managing cardiovascular risk. 

Because those sorts of people, let's say an 80-year-old with a GFR of 40 and no albuminuria, they're never going to get renal failure, but they do have increased risk of cardiovascular disease. And then it's back to Mel's very important point. You know, a nursing home resident may not need anything being done, but the still working judge playing tennis will want to have maximal protection for any cardiovascular risks. And of course, the other challenge is that intercurrent illnesses upset this balance, don't they? 

So somebody then getting flu, or pneumonia, or a broken hip; actually, they'll get an episode of acute kidney injury. And that does change the balance of how you might need to manage it. But that's for a different conversation. 

So let's go, Mel and Andrew. We talked before in previous episodes about various medications that we're using extensively for chronic kidney disease:  ACE inhibitors, angiotensin blockers, SGLT2 inhibitors…

For listeners new to this, there were three excellent podcasts in our previous series about ACE inhibitors, and a role for old drugs in old people — this is what's going to be now — but also the role for these newer drugs, SGLT2 inhibitors. Should we be using these in older people with chronic kidney disease?

Andrew Frankel

So Jeremy, we come back to the problem that guidelines, most particularly NICE guidelines, do not make special reference usually to age or indeed frailty. And you have really blanket guidelines that may not be relevant to those who are more frail.

In determining if you're going to treat a person with CKD, the key question you're going to ask yourself, when they're sitting in front of you, is will this individual get benefit from the medication I would like to recommend? i.e. is it going to prevent cardiovascular event, or is it going to prevent progression to CKD?

We know that the SGLT2 inhibitors offer significant cardio-renal benefit in relation particularly to hospitalisation for heart failure as well as preventing CKD decline. And when the patient is elderly with multi-morbidity, that is still the case.

So for individuals with CKD, and particularly if they also have heart failure treatment, the SGLT2 inhibitors will help improve quality of life and reduce frequency of admissions. In regard to RASI and particular ACE inhibitors, we know that these agents provide significant quality of life benefit for people with heart failure who have reduced ejection fraction. So you should still be using them in that context.

So you can take that approach so far. But there are also patients who have such bad multi-morbidity, I'm sure Mel will be wanting to pick this up, such as this 75 year old in a nursing home who may not be able to get out of bed, that puts them in a situation that they're really close to end of life.

And these individuals you need to consider whether it's reasonable to add an extra medication and for many of these cases it may be best to avoid this, and consider a more supportive approach. 

However, coming back to this comparison we've described before. For an elderly person, perhaps not even more than 75, I'm going to take that judge, but I'm going to make him 85, still playing occasional tennis without any albuminuria, with no heart failure, one can say, he likely, even if he's got a GFR of 40 and you said this Jeremy, he's not likely to reach end-stage adrenal failure. so adding the SGLT2 inhibitor to him may not provide him benefit in his lifetime.

And that, I think, will influence the decision that you make.

Melanie Dani

Thanks, Andrew. I agree with all of that. And ultimately, if we feel the treatment that we're proposing has more benefits than side effects, then this is a good place to start. And it's always useful to consider what the side effects are and again, take this back to the patient with shared decision-making. So if it's a side effect that's annoying, for example, orthostatic hypotension, but they can tolerate it, then it's still reasonable to continue it. But of course, we need to review things over time as well.

If somebody becomes frail, for example, if they have that hospital admission that Jeremy was talking about, or develop side effects that become intolerable, then the benefit may no longer be apparent. One side effect of both SGLT2 inhibitors and ACE inhibitors is orthostatic hypotension. And I often find that if patient suffers from falls or presyncope or orthostatic hypotension, this can take over as the dominant problem.

And if the patient is struggling to get up or walk or have a good quality of life, then the benefits may reduce over time as frailty progresses. So, once we've started the medication, we should always continue to check that the benefits outweigh the side effects. And Andrew, you also mentioned a palliative — or a supportive or palliative approach in some patients. And I just want to pick up on that because we know that the surprise question is a validated and very useful tool for advanced care planning. That is, would I be surprised if this patient dies in the next year?

I find this question very useful, because if the answer is no, I wouldn't be surprised if this patient would die in the next year, it's a really good time to think about our goals of treatment and to talk to the patient and their families, again, about their values and preferences, and to consider other things which may also add benefit, whether it's extra social support or symptom management, even if it's alongside these medical managements that we've been talking about.

Jeremy Levy

That's really helpful, Mel. I was going to add one other comment to what you've both been saying. And if we're considering using drugs like SGLT2 inhibitors, and angiotensin blockade, and ACE inhibitors, we've also got to make sure that the person we're treating can maintain good hydration and is aware of things like six day rules, because both of these drugs, we need some understanding about how to use them safely. So I think we should hand over to Mel for the final comments, really. I hope that we've covered a whole range of topics here that we think are very important. But, Mel, give us your final thoughts.

Melanie Dani

So just to say thank you so much, Andrew and Jeremy, for giving me this very important topic discussion. I think the key takeaway from this, really, is that we need to always ask these questions as the first step in providing personalised healthcare. What am I doing for the patient in front of me? Is it going to provide them benefit? What are the side effects, and how does this fit with the overall context of the person's health and life? Not to mention how their GFR fits into the rest of their life.

Jeremy Levy

So that's been really helpful and actually, you know, ending thinking about the person and not just a GFR number. I think I've got three or maybe four take-home messages that I'm going to try and remember. Firstly, kidneys definitely age and GFR drops. But if there's no albinouria and no other systemic illnesses, the risk from this absolutely is low, but there are still increased risks overall. We're thinking about some renal referral discussion with secondary care.

Think about both, are we trying to diagnose a problem or prepare for renal failure or further advances or not? And then, treatment of chronic kidney disease will mostly be guided by overall frailty, symptoms, and other conditions, particularly things like heart failure, and the ability of people to take medication safely. And my fourth take home was this constant reminder of age versus frailty, that some old people are very fit, and other, actually even younger people, are frail.

These are not the same, and certainly in managing CKD, chronic kidney disease, we must consider frailty and age as separate entities. And I think those are the key things that I'm going to remember. Mel, it's been a pleasure having you here. Thank you very much for joining us today.

Melanie Dani

Thank you, it's been a real pleasure to be here.

Andrew Frankel 

Great to be doing this with you, Mel, and thank you so much, and thanks Jeremy for sharing this podcast so — well despite comments about my age.

Jeremy Levy

Bye

Bye!

Thank you, Mel!