Geriatric nephrology and urology最新文献

Because of its high blood flow and function to excrete and metabolize xenobiotics, the kidney is especially prone to injury by drugs and chemicals. In elderly patients, renal function is also often reduced by age itself or comorbid diseases leading to a high incidence of adverse drug reactions both to the kidney itself and to other organs because of drug accumulation. This paper reviews this issue with specific emphasis on drugs that are often used in elderly subjects such as nonsteroidal antiinflammatory agents, angiotension converting enzyme inhibitors, antibiotics, and immunosuppressive drugs.

The 'demographic imperative' of a progressively aging society will place unprecedented demands on the health care system in the 21st century. Although improved education, public health measures, personal lifestyles, and health care will result in a large proportion of those born surviving to old age in robust health and vitality, the sheer numbers of 'baby-boomers' who will become the elderly and the inevitable association between aging and the associated multiple, especially chronic diseases and physiological impairments of old age will require more efficient and more effective systems of health care to meet the needs of the aging population. Generalists, specialists, and medical and surgical subspecialists will play important roles in meeting these needs, often in the multidisciplinary mode. Geriatricians will directly provide but a small minority of the care, focusing upon education, research, and consultation and in delivering primary care to the frail elderly and especially in long term care. Collaboration with subspecialists will be frequent in all these domains. Nephrologists, who already practice multidisciplinary team care of frail, complicated, chronically ill patients with end-stage renal disease, have much to contribute as their patient population progressively grows in numbers and age. Hence geriatricians and nephrologists have much to learn from and contribute to each other in addressing the 'age wave' of the 21st century.

Both aging and chronic renal failure (especially end-stage renal disease) are characterized by a low bone turnover disorder. In aging, the senile form of osteoporosis may be related to a decrease in stem cells differentiating towards osteoprogenitors, while in CRF there is a decrease in the capacity of the osteoblast differentiation program in the absence of the influence of PTH. In both aging and CRF, secondary hyperparathyroidism is common. Thus, the impact of chronic renal failure on skeletal homeostasis in the elderly may be superimposition of an additional factor producing a deficiency of osteoprogenitors. Compensation through higher PTH levels results in an increase in resorptive activity. The long term clinical result of superimposing CRF on senile osteoporosis is unknown due to shortened survival of the population, but the risk of excess bone resorption is realized as survival is increased. From the above pathogenetic discussion of renal osteodystrophy and senile osteoporosis, the need for improved and specific therapeutic approaches is clear. At the present time, our treatments do not adequately consider the superimposition of chronic renal failure and renal osteodystrophy on the aging skeleton that may have osteoporosis.

Background: Short-acting nifedipine was found to be associated with increased mortality in elderly patients in some studies.

Methods: We examined effects of long-acting nifedipine in a longitudinal study of Jerusalem 70 year olds (448 participants).

Results: After follow-up of 6.5 years (1990-1996) 70 subjects died. We examined the effects of baseline variables on total mortality. Hypertensives had higher mortality than normotensives, 21.2% versus 13.8%, p = 0.01. Diuretic-treated patients (n = 72), mostly hypertensive (n = 71), had significantly higher mortality than non-diuretic-treated patients (n = 375), 45.5% versus 14.1%; p < 0.001. Although nifedipine-treated patients had a higher prevalence of coronary heart disease diagnosis than diuretic-treated patients (52% versus 35%), their relative risk of mortality was 0.8 (CI 0.4-1.4) of that of diuretic-treated patients. A multiple logistic regression model, including gender, systolic blood pressure, creatinine, cholesterol, diagnosis of congestive heart failure, cardiovascular arrest, diabetes, previous myocardial infarction, physical activity, nifedipine, other calcium channel and beta blockers and diuretics, found only serum creatinine and diuretic therapy associated with total mortality, p = 0.004 and p < 0.02, respectively. When interaction terms were added to account for drug combinations, diuretic therapy lost significance, but the combination of diuretics and beta blockers (probably representing a more severe form of hypertension) became significant, p = 0.03.

Conclusion: Long acting nifedipine is not associated with increased mortality in elderly hypertensives.

Over 30 million men and their partners suffer the effects of erectile dysfunction. Erectile dysfunction results in significant psychological, social and physical morbidity; requiring a comprehensive and compassionate approach by the health care provider. The article reviews the epidemiology, pathophysiology and clinical presentation of erectile dysfunction. It provides a comprehensive, outcome-based evaluation of current treatment modalities.

There are an increasing amount of data which are compelling us to consider the issue of age in dealing with decisions regarding both renal transplant recipients and donors. These geriatric issues in transplantation can be summarized as follows: (1) The explosion of a geriatric population of patients with ESRD, in association with data showing a survival advantage of transplantation over wait-listed dialysis patients, demands an increase in expertise in transplantating patients over 60 years old. (2) The critical shortage in cadaveric organ supply is creating a variety of solutions including expanding the donor pool with older kidneys in which long term survival may be shorter than in kidneys from younger donors. (3) The donor shortage, in association with data demonstrating improved survival of living related and unrelated donor transplants, is generating an increased number of older (> 60 years old) individuals who want to donate to a relative, spouse or friend. Future efforts should be directed toward continued research designed to evaluate the efficacy and safety of these trends. We also need to provide improved training in geriatrics for nephrologists so that we and transplant surgeons can deliver better medical care to an aging population of patients with ESRD.

Objective: To investigate the glomerular and proximal tubular renal function and the prevalence of urinary abnormalities in the elderly.

Design: Cross-sectional study.

Setting: General community in the city of São Paulo.

Participants: A population-based sample of 200 elderly subjects was randomly selected. Of these, 81 subjects (45 females and 36 males; mean +/- SD age: 73.7 +/- 6 years) accepted to undergo laboratory examination and were included in the study.

Main outcome measures: 24-h creatinine clearance (CCr), microalbuminuria, urinary retinol-binding protein (urRBP), leukocyturia, hematuria and total proteinuria.

Results: CCr was lower than 80 ml/min/1.73 m2 in 68% of the subjects. The median (range) CCr was 65 ml/min/1.73 m2 (21-112) in males and 77 ml/min/1.73 m2 (27-107) in females (p = 0.14). No individual had serum creatinine greater than 1.5 mg/dl. urRBP determination was normal in 79 of 81 subjects. The prevalence of microalbuminuria (> 20 micrograms/ml) was 31% (n = 25, 19 men and 6 women). These individuals presented higher mean systolic blood pressure (147 +/- 20 vs. 135 +/- 22 mmHg, p = 0.02) and mean serum creatinine (1.13 +/- 0.20 vs. 0.96 +/- 0.20 mg/dl, p < 0.01) than those without microalbuminuria. The prevalence of leukocyturia (> 10,000/mm3), hematuria (> 10,000/mm3) and total proteinuria (> or = 0.3 mg/dl) was 19%, 28% and 5% in males and 33%, 27% and 4% in females.

Conclusions: Glomerular dysfunction and urinary abnormalities are frequent features in the elderly, however, proximal tubular dysfunction is uncommon in this population.