In Anlehnung an die aktualisierte gemeinsame S3-Leitlinie der DEGAM und der DGfN „Versorgung von Patientinnen und Patienten mit chronischer, nicht-nierenersatztherapiepflichtiger Nierenkrankheit in der Hausarztpraxis“ werden in diesem Artikel praxisnahe Empfehlungen für das Management der chronischen Nierenkrankheit (CKD) dargestellt. Der Großteil der Patientinnen und Patienten mit CKD wird im hausärztlichen Setting betreut.

Die chronische Nierenkrankheit („chronic kidney disease“, CKD) betrifft etwa 10

Von einer chronischen Nierenerkrankung Betroffene weisen besonders häufig, mit dem Schweregrad zunehmend und oft bereits in relativ jungem Alter, Charakteristika geriatrischer Patient*Innen auf. Ein geriatrischer Phänotyp, oft mit dem Begriff „frail“ umschrieben, obgleich mit diesem nicht synonym, geht neben erhöhter Mortalität u. a. mit einem erhöhten Risiko für schwerere und prolongierte Krankheitsverläufe sowie einer häufig damit assoziierten Abnahme der Selbsthilfefähigkeit und der Autonomie, aber auch einer geringeren Chance, nierentransplantiert zu werden, einher. Um dem zu begegnen, sollten Patient*Innen zunächst gescreent und bei Auffälligkeiten dann in einem Assessment zumindest in den Dimensionen Selbsthilfefähigkeit, Mobilität, Kognition, Affekt, Ernährung und soziale Situation auf Defizite abgeklärt werden. Weitere Bereiche wären z. B. Multimedikation und Symptomlast. Prognosescores können bei schwerwiegenden diagnostischen oder therapeutischen Entscheidungen hilfreich sein. Ziel eines Assessments ist es, individuelle Probleme frühzeitig zu erkennen und gezielt Maßnahmen einzuleiten, um damit die Selbsthilfefähigkeit und die Lebensqualität der Betroffenen bestmöglich zu erhalten.

Multimorbidity, i.e. the simultaneous presence of 2 or more diseases, is common in patients with chronic kidney disease (CKD). Cardiovascular diseases such as coronary heart disease, heart failure, stroke or vascular dementia are of particular importance. CKD and comorbidities influence each other, which is why the current KDIGO guidelines emphasize the need for personalized treatment approaches. This applies in particular to older patients, who are especially frequently affected by CKD. The diagnosis of CKD patients should not only include typical comorbidities, but also a comprehensive risk assessment and an evaluation to avoid polypharmacy. Recognising CKD is of particular importance for patients with chronic diseases in old age, as kidney disease can have a profound effect on or worsen the course of other diseases and the limitation of kidney function has a significant influence on the treatment approach. Particular attention must be paid to the correct assessment of kidney function in older people in terms of determining the estimated glomerular filtration rate (eGFR). Here, a measurement of serum creatinine is not always sufficient due to lower muscle mass and may need to be supplemented by additional parameters to estimate the glomerular filtration rate, such as cystatin C. Depending on the eGFR, kidney disease is categorized into the stages CKD G1-G5. In addition, if kidney disease is suspected, a test for proteinuria should also be performed, preferably as a measurement of albumin excretion in spontaneous urine (albumin-to-creatinine ratio, ACR). Geriatric screening and assessment are also crucial to recognize the multimorbidity, frailty and psychosocial aspects of older patients. The treatment of multimorbidity in CKD patients focusses on progression reduction and secondary and tertiary prevention, whereby a healthy lifestyle, regular exercise and a balanced diet are also important. The prevention of cardiovascular disease, particularly in the case of high blood pressure and diabetes mellitus, requires individualized therapy, in which the choice and dosage of medication must also be taken into account, particularly in the case of advanced renal impairment. If heart failure and/or atrial fibrillation are also present, close interdisciplinary collaboration between nephrologists, cardiologists and GPs is helpful in order to optimize treatment. In addition, CKD patients with dementia face particular challenges in terms of medication and the avoidance of delirium and mental symptoms.

Die chronische Nierenkrankheit (CKD) ist mit einer Prävalenz von 10

A decline in glomerular filtration rate (GFR) is considered a physiological change in older age. Accurate estimation of the eGFR is essential not only for establishing a diagnosis but also for selecting appropriate medications and determining correct dosages, in order to avoid both under- and overdosing, as well as associated adverse drug reactions. In patients with signs of sarcopenia, relying solely on serum creatinine or creatinine-based eGFR may lead to an overestimation of kidney function. In older adults, the most accurate estimation of eGFR is achieved by using equations that combine creatinine and cystatin C. The currently recommended EKFC equation has been well validated in a large cohort of older European individuals. In cases of suspected kidney disease, a spot urine test for albumin and creatinine - with calculation of the albumin-to-creatinine ratio (UACR) - should also be performed in older adults.

Patients affected by chronic kidney disease very often exhibit the characteristics of geriatric patients, which increase with the severity and often already at a relatively young age. A geriatric phenotype, often described with the term frail, although not synonymous with it, is associated with increased mortality, with an increased risk of more severe and prolonged disease progression and, frequently associated with this, a decrease in the ability for self-help and autonomy as well as a lower chance of undergoing a kidney transplantation. In order to counter this, patients should first be screened and, in the event of abnormalities, the deficits should be assessed at least in the dimensions of the ability for self-help, mobility, cognition, affect, nutrition and social situation. Other areas would be, for example, polypharmacy and symptom burden. Prognosis scores can be helpful when making difficult diagnostic or treatment decisions. The aim of an assessment is to identify individual problems at an early stage and to initiate targeted measures in order to maintain the ability for self-help and the quality of life of the patients in the best possible way.

When elder individuals develop chronic kidney failure, doctors, patients, and family members are faced with the decision: Should dialysis (still) be initiated, or should a conservative-palliative therapy strategy be chosen? A prerequisite for shared decision-making is structured education about the various options, ensuring all necessary information and consequences are communicated. This article outlines the advantages and disadvantages of haemodialysis and peritoneal dialysis, as well as conservative-palliative therapy. Additionally, it discusses the option of a trial dialysis and the choice to discontinue ongoing dialysis.

When elder individuals develop chronic kidney failure, doctors, patients, and family members are faced with the decision: Should dialysis (still) be initiated, or should a conservative-palliative therapy strategy be chosen? A prerequisite for shared decision-making is structured education about the various options, ensuring all necessary information and consequences are communicated. This article outlines the advantages and disadvantages of haemodialysis and peritoneal dialysis, as well as conservative-palliative therapy. Additionally, it discusses the option of a trial dialysis and the choice to discontinue ongoing dialysis.

When elder individuals develop chronic kidney failure, doctors, patients, and family members are faced with the decision: Should dialysis (still) be initiated, or should a conservative-palliative therapy strategy be chosen? A prerequisite for shared decision-making is structured education about the various options, ensuring all necessary information and consequences are communicated. This article outlines the advantages and disadvantages of haemodialysis and peritoneal dialysis, as well as conservative-palliative therapy. Additionally, it discusses the option of a trial dialysis and the choice to discontinue ongoing dialysis.