Empowering Elderly Patients - Tools for Effective Management of Glomerular Damage

Introduction

Damage to the kidneys or kidney diseases are very common among older people and affect the patient's overall health. The glomerulus is part of the kidney that helps filter out the body's waste and toxins and excrete it outside. The glomerular disease affects the glomerulus of the kidney, thereby affecting its normal functioning. Doctors face various challenges while managing primary glomerular diseases in terms of biopsy, diagnosis, and immunosuppressive medications. Membranous nephropathy was the most common type and frequent cause of glomerular damage in the older population. However, diagnosing and managing glomerular damage with immunosuppressive agents is still challenging because of various factors like comorbidities, life expectancy, and the side effects associated with the drug.

What Are the Different Glomerular Diseases Affecting the Elderly People?

Various primary glomerular diseases affecting older adults are:

• Nephritic syndrome or nephrotic syndrome is a kidney condition that makes the body excrete an excessive amount of protein in the urine. The clusters of tiny blood capillaries in the kidneys that filter waste and extra water from the blood are typically damaged by nephrotic syndrome.

• Chronic glomerulonephritis is inflammation of the small filters of the kidneys (glomeruli). Urine is the body's method of excreting the extra fluid and waste that glomeruli remove from circulation.

• RPGN (rapidly progressive glomerulonephritis) is a clinical phenomenon that shows signs of glomerular disease in the urine and gradually diminishes kidney function over a relatively short period (days, weeks, or a few months).

• Membranous neuropathy (It is an autoimmune condition where the body's defense system acts opposite towards the body).

• FSGS (focal segmental glomerulosclerosis) is scar tissue in the kidney's filtration system. "Focal" refers to the scarring of a few glomeruli.

• IGA neuropathy is one of the most serious manifestations of glomerular diseases seen in the elderly.

• Pauci-immune crescentic glomerulonephritis is common in both elderly and old age groups. Pauci - immune crescentic glomerulonephritis should be diagnosed and treated urgently as it is an emergency for elderly people with an increased risk of end-stage renal diseases. Renal biopsies should be recommended as a priority in these cases.

What Are the Challenges Faced by the Clinicians While Managing Glomerular Disease in Elderly People?

There are several challenges doctors face when managing elderly people with glomerular damage. Different factors that add the challenges for clinicians to manage the glomerular disease are:

• Comorbidities (Elder patients with underlying systemic diseases like hypertension, diabetes, etc.).

• Side effects associated with immunosuppressive drugs.

• Decreased muscle mass in the elderly results in an overestimated range of GFR (glomerular filtration rate) with creatinine levels.

• Compromised immune system with age, existing systemic diseases, and ongoing medications with potential drug interactions.

• Increase the risk of infections due to compromised immune systems.

• Drug toxicity is due to the increased serum concentration of the drug because of poor metabolism and excretion of the drug with aging.

• Expected life - expectancy.

• Kidney functions at the time of diagnosis.

• Difficulty in performing renal biopsies due to risk of bleeding and underlying comorbidities.

What Are the Management Guidelines for Glomerular Damage in Elderly People?

Different guidelines implemented for the management of glomerular damage in elderly people are:

1. Conservative Management:

• Different conservative management strategies used to treat glomerular damage in elderly people are:

• Reduction in salt intake.

• Cessation of habits like smoking.

2. Pharmacological Management: Various drug therapies induced to manage nephrotic syndrome patients are:

• Diuretics.

• RAS -Blockers (renin-angiotensin system blockers).

• Statins.

• Anticoagulant agents are administered in patients with serum albumin levels below 2 grams per deciliter.

• Pneumococcal vaccination.

3. Immunosuppressive Therapy: It is mostly preferred in patients with declining renal functions after the diagnosis. Immunosuppressive therapy is preferred over conservative management in such patients, especially in the cases of nephrotic proteinuria (a condition in which protein excretion is more than 3.5 grams per hour).

All these guidelines have been implemented to manage glomerular damage in elderly people. However, the decision for the treatment should be made wisely by the clinicians keeping in mind the pros and cons of various treatment modalities and the underlying factors that pose a risk while managing glomerular diseases, such as existing comorbidities, reduced metabolism, and compromised immune system with age. The diagnosis and management are also decided based on the individual health condition and after monitoring renal function during the diagnosis.

What Are the Current Guidelines Recommended by Kidney Disease Improving Global Outcomes (KDIGO) For the Management of Glomerular Damage?

KDIGO (Kidney Disease Improving Global Outcomes) has implemented a few guidelines in the year 2021 for the management of glomerular diseases, such as:

• Biopsy of the kidney should be considered a gold-standard diagnostic tool.

• Assessment of the kidney function for ruling out the protein levels of the urine. A sample of urine should be collected and tested within 24 hours. Glomerular filtration rate and creatinine clearance should be assessed to determine kidney function.

• Management of underlying systemic diseases like hypertension, diabetes, and metabolic acidosis.

• Pharmacological management using drugs such as loop diuretics and thiazides should be done to control serum potassium levels.

• Implementing lifestyle modifications like restricting sodium intake, regular exercise, and proper diet.

• It is recommended to give a prophylactic Trimethoprim-Sulfamethoxazole combination for all patients undergoing management using immunosuppressive agents.

• The glomerular filtration rate levels should be kept in mind before the induction of the drug therapy to determine the safe drug dosage based on the individual's condition.

• Choose the drug regimen wisely to reduce the side effects of the immunosuppressant drugs and minimize the progression of the disease.

Conclusion

Damage to the glomerulus of the kidney is a very common condition among elderly patients. Various factors like underlying systemic diseases, life expectancy with age, drug interactions, reduced metabolism, compromised immunity, and increased risk of bleeding as well as infections are a few factors that pose a greater impact and challenges to the clinician during the diagnosis and management of the glomerular damage in elderly patients. However, the doctor should make a wise decision for early diagnosis and management of the patient's condition by keeping in mind various associated comorbidities and other factors. Furthermore, using immunosuppressive therapy over conservative approaches poses a big challenge for the clinician and the patient. Therefore, early diagnosis and wise management strategies are recommended to manage adults' glomerular damage.