Management of Kidney Disease in Older Adults
Older adults with chronic kidney disease require a modified management approach that prioritizes prevention of frailty and sarcopenia over strict dietary restrictions, with careful attention to blood pressure targets based on fall risk and life expectancy. 1
Nutritional Management: Age-Specific Modifications
Protein Intake
- Increase protein intake above the standard 0.8 g/kg/day recommendation when frailty or sarcopenia is present 1
- The standard CKD recommendation of 0.8 g/kg/day applies only to older adults without frailty or muscle wasting 1
- Higher calorie targets should accompany increased protein to maintain muscle mass and functional status 1
- Critical caveat: This directly contradicts the general CKD population guidance to avoid high protein intake (>1.3 g/kg/day), but preserving muscle mass and preventing functional decline takes priority in frail older adults 1
Sodium Restriction
- Target sodium intake <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 1
- Exception: Do not restrict sodium in patients with sodium-wasting nephropathy 1
Dietary Pattern
- Emphasize plant-based foods over animal-based foods and minimize ultraprocessed foods 1
- Consider Mediterranean-style diet to reduce cardiovascular risk 1
- Utilize renal dietitians for individualized education on sodium, phosphorus, potassium, and protein adaptations 1
Blood Pressure Management: Balancing Benefits and Risks
Target Blood Pressure
- Standard target: Systolic BP <120 mm Hg when tolerated using standardized office measurement 1
- Modified approach for high-risk older adults: Consider less intensive BP-lowering therapy in those with:
This represents a critical decision point where mortality from falls may outweigh cardiovascular benefits of aggressive BP control 1.
Cardiovascular Risk Reduction
Statin Therapy
- All adults ≥50 years with eGFR <60 mL/min/1.73 m² (stages G3a-G5) should receive statin or statin/ezetimibe combination 1
- Adults ≥50 years with eGFR ≥60 mL/min/1.73 m² should receive statin therapy 1
- Choose statin regimens that maximize absolute LDL cholesterol reduction 1
- Consider PCSK-9 inhibitors when indicated 1
Antiplatelet Therapy
- Low-dose aspirin for secondary prevention in those with established ischemic cardiovascular disease 1
- Consider alternative antiplatelet agents (P2Y12 inhibitors) with aspirin intolerance 1
Physical Activity Recommendations
Exercise Prescription
- Encourage regular physical activity while avoiding sedentary behavior 1
- For older adults at higher fall risk: Provide specific guidance on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance) 1
- Exercise improves aerobic capacity, walking ability, blood pressure, heart rate, and quality of life 2, 3
- Physical activity recommendations must account for age, comorbidities, and fall risk 1
Renin-Angiotensin System Inhibition
Indications
- Strongly recommended for CKD with severely increased albuminuria (A3) without diabetes 1
- Strongly recommended for CKD with moderately-to-severely increased albuminuria (A2-A3) with diabetes 1
- Suggested for moderately increased albuminuria (A2) without diabetes 1
Monitoring
- Check BP, serum creatinine, and potassium within 2-4 weeks of initiation or dose increase 1
- Manage hyperkalemia with potassium-lowering measures rather than discontinuing RASi when possible 1
Key Clinical Pitfalls in Older Adults
Overrestricting protein: Unlike younger CKD patients, older adults with frailty need higher protein intake to prevent sarcopenia, even if this theoretically accelerates CKD progression 1
Aggressive BP lowering: The standard <120 mm Hg target may cause falls, fractures, and hypotension in frail older adults with limited life expectancy 1
Fluid restriction without assessment: Older adults with CKD stage 4 require individualized fluid management based on volume status, urine output, and sodium levels 4
Ignoring cardiovascular risk: Statin therapy is strongly indicated regardless of age when eGFR <60 mL/min/1.73 m² 1