Dimitrios G. Oreopoulos
Nada Dimkovic
Toronto Western Hospital,
University Health Network

Introduction
The elderly (>65 years) are the fastest growing group of patients who require dialysis. In 1988, of the more than four thousand new dialysis patients, one thousand nine hundred and fifty eight were 65 years or older, giving an approximate rate of 515 new patients per million members of the population.

Once an elderly patient has developed end-stage renal disease (ESRD), his/her therapeutic options become limited to the various modes of dialysis that are available and, to a lesser degree, to renal transplantation.

Here we should mention a word of caution with regards to using serum creatinine as a guide for the point at which to begin dialysis. Because of the decrease in muscle mass that is associated with age, serum creatinine is disproportionately low for the degree of renal failure. Rather than relying on serum creatinine, either a creatinine clearance, or the Cockroft-Gault formula should be used to assess the severity of renal failure.

Although renal transplantation may be successful in the elderly person with ESRD, and they may have renal graft and patient survival rates comparable to those of younger recipients, only a small percentage (0.5-3%) of these patients are undergoing transplant procedures. The main reason for this is the shortage of donor kidneys.

More than ten thousand physicians and scientists from around the globe recently gathered in Toronto to attend the American Society of Nephrology's 'Renal Week'; a meeting that has been termed the 'pre-eminent meeting for kidney disease'. The first few days of the conference consisted of pre-annual meeting courses, which were held from October 10-12, followed by the 33rd Annual meeting and Scientific Exposition, held from October 13-16.

The rundown of events included postgraduate education courses, the American Society of Nephrology Basic Science Conference, a Professional Development Seminar and finally the 33rd Annual Meeting and Scientific Exposition.

The postgraduate courses that were offered included an informative program on the multi-system effects of hypertension, with a particular stress placed on the management of these conditions. Another highlight section investigated the practical insights required to effectively plan and maintain various invasive and diagnostic procedures using in the management of nephrology patients.

The goal of the 2000 ASN Basis Scientific Conference was to determine the ramifications of various emerging developments in genetics and cellular and molecular biology on understanding the pathogenesis of kidney diseases, and on therapies for these diseases. Approaches to identifying susceptibility to nephropathy genes and various approaches to testing novel targets for therapy for progressive kidney disease were presented.

One of the highlights of the week was the announcement that researchers have discovered a Kidney Injury Molecule - 1 (KIM-1) in damaged animal and human kidneys, which may have implications for the early detection of acute renal failure (ARF). ARF is a major complication among hospitalized patients and, despite advances in supportive care, is associated with a significant fatality rate. Traditional blood and urine tests do not allow for early detection of the disease, particularly in patients with normal baseline kidney function. It is thought that the introduction of therapy, early in the disease process, is likely to lead to a reduction in fatality rates associated with ARF.

To test whether the presence of the KIM-1 protein in the urine serves as an early marker of ARF, the researchers collected and analyzed samples from patients suffering from a variety of different types of kidney disease. The amount of KIM-1 protein was noticeably greater in urine samples from patients with ARF, and was associated with either decreased blood flow to the kidney or a severe generalized infection. Until recently, efforts to measure proteins in the urine that can be used as general markers to screen and identify the site of injury within the kidney have been disappointing. This research comes at a time of growing demand for new methods to detect kidney failure at an early stage by using minimally invasive tests.

The most common renal disorders in the elderly are nephrotic syndrome (characterized by severe proteinuria), glomerulonephritis, renal artery stenosis and acute or chronic renal failure. Therapeutic options available for elderly patients who develop end-stage renal disease (ESRD), include the various modes of dialysis, and to a lesser degree, renal transplantation. Progressive renal disease from all etiologies remains a significant health-care problem. Currently, there are more that 2,800 Canadians on a waiting list to receive a kidney transplant. The number of patients requiring ESRD therapy continues to increase despite improvements in blood pressure control and improvements associated with the advent of ACE inhibitor therapy.

For more information on the American Society of Nephrology's Renal Week, please visit their website at www.asn-online.com. Please also see next month's issue of Geriatrics & Aging in which several leading experts will discuss the diagnosis and currently available treatments of Renal Diseases in the elderly. Topics will include dialysis in the elderly, acute and chronic renal failure and how to do a work up to test patients for Proteinuria.

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