# Geriatric Nephrology: Managing CKD and AKI in Elderly Patients

## Learning Objectives

By the end of this session, students will be able to: - Understand physiologic changes in renal function with aging - Interpret eGFR and creatinine appropriately in elderly patients - Apply age-specific drug dosing adjustments in CKD - Assess frailty and functional status in geriatric CKD patients - Recognize and manage polypharmacy in elderly with kidney disease - Diagnose and treat AKI with age-specific considerations - Make evidence-based CKD progression decisions in elderly populations

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## I. Normal Kidney Aging and eGFR Decline

### Physiologic Changes with Aging

The kidney undergoes predictable structural and functional changes with advancing age:

| Parameter | Age 20–40 | Age 65–75 | Age 80+ | Clinical Significance |
|----|----|----|----|----|
| **GFR (mL/min/1.73m²)** | 95–105 | 55–75 | 30–55 | Progressive decline |
| **Nephron loss** | 1 million/kidney | Loss of 30–50% | Loss of 40–60% | Loss of reserve capacity |
| **Tubular function** | Normal | ↓ Reabsorption, ↓ secretion | Significant decline | Impaired drug clearance |
| **Renal blood flow** | 600 mL/min | 400 mL/min | 300 mL/min | Reduced perfusion |
| **Creatinine production** | Normal | ↓ 20–30% | ↓ 30–50% | Masked renal dysfunction |
| **Serum creatinine** | 0.8–1.0 | 0.9–1.2 | 1.0–1.3 | May appear “normal” |

### The Critical Concept: Creatinine ≠ GFR in Elderly

**Key Point:** A “normal” serum creatinine of 1.0 mg/dL in an 85-year-old represents **significant renal impairment** because: - Elderly patients produce less creatinine (reduced muscle mass, lower metabolism) - The KDIGO CKDEPI equation accounts for age, accounting for lower muscle mass - An 85-year-old with Cr 1.0 mg/dL may have GFR ~30–40 mL/min/1.73m², not 100

**Clinical Pearl:** Never assume “normal creatinine” = “normal kidneys” in elderly patients. Always calculate eGFR using the CKD-EPI equation, which is preferred over Cockcroft-Gault in all populations.

### Expected vs. Pathologic GFR Decline

- **Expected:** 1 mL/min/1.73m² per year after age 40
- **Pathologic:** Decline \>3–4 mL/min/1.73m² per year indicates progressive kidney disease
- **Recommendation:** Classify elderly patients with GFR 45–59 as CKD stage 3b, but recognize that many live well without further intervention if stable

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## II. eGFR Interpretation in Elderly: When NOT to Refer

### Risk-Benefit Analysis of Nephrology Referral in Elderly

Referral to nephrology is **not always indicated** simply based on low eGFR. Consider:

#### Patients Who NEED Nephrology Referral:

1.  **Rapidly declining GFR** (\>4 mL/min/year or acute change)
2.  **Significant proteinuria** (UACR \>300 mg/g or nephrotic-range proteinuria)
3.  **Hematuria with cellular casts** (glomerulonephritis)
4.  **Resistant hypertension** despite 3+ agents
5.  **CKD G4 or G5** with expected lifespan \>5 years
6.  **Symptoms** (uremia, volume overload, hyperkalemia)
7.  **Consideration of dialysis** or transplant

#### Patients Who MAY NOT Need Referral:

- Stable CKD G3a–G3b (eGFR 45–59) in patients \>75 years with expected lifespan \<5 years
- Asymptomatic, normotensive CKD G3b without proteinuria
- Incidental low eGFR found on routine labs with no other indicators of kidney disease
- Very elderly (\>85) with stable, slowly declining eGFR and multiple comorbidities

#### Age-Based Screening Recommendations

- **Screen annually:** Patients 65–75 with diabetes or hypertension
- **Selective screening:** Patients \>75 only if presenting with symptoms or acute change
- **Consider benefits:** Early CKD diagnosis in very elderly may lead to unnecessary testing and anxiety without clear benefit

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## III. Geriatric Drug Dosing in CKD

### Age-Related Pharmacokinetic Changes

Elderly patients have altered drug metabolism and clearance:

| Factor | Effect | Clinical Consequence |
|----|----|----|
| **↓ Renal blood flow** | ↓ Drug clearance | Accumulation |
| **↓ GFR** | ↓ Glomerular filtration | Prolonged half-life |
| **↓ Tubular secretion** | ↓ Active drug elimination | Higher drug levels |
| **↓ Hepatic metabolism** | ↓ First-pass metabolism | Increased bioavailability |
| **↑ Body fat** | ↑ Lipophilic drug volume of distribution | Prolonged effects |
| **↓ Plasma protein binding** | ↑ Free drug fraction | Increased pharmacologic activity |
| **Polypharmacy** | ↑ Drug interactions | Unpredictable effects |

### Drug Dosing Adjustments by eGFR in Elderly CKD

#### Common Medications Requiring Adjustment:

**ACE Inhibitors/ARBs:** - eGFR \<30: May require dose adjustment; monitor K+ carefully - Avoid dose escalation; lower target doses often sufficient - Ramipril 1.25–5 mg daily (vs. up to 10 mg in younger patients)

**Beta-Blockers:** - eGFR \<30: Atenolol, nadolol require 50% dose reduction - Prefer metoprolol or carvedilol (hepatically metabolized) - Start low, titrate slowly

**Thiazide/Thiazide-Like Diuretics:** - eGFR \<30: Less effective; switch to loop diuretics if needed - Chlorthalidone more potent than HCTZ; use caution in elderly

**NSAIDs:** - **Avoid entirely** in CKD G3b and worse; extremely high risk of acute deterioration - Consider selective COX-2 inhibitors (celecoxib) if absolutely necessary, with gastroprotection and renal monitoring

**Anticoagulation:** - **Warfarin:** eGFR \>30 no adjustment; \<30 may require closer INR monitoring - **DOACs:** Reduced dosing commonly needed in elderly with CKD: - Apixaban: 2.5 mg BID if age ≥60 + weight ≤60 kg + Cr ≥1.5 mg/dL - Rivaroxaban: 15 mg daily (not 20 mg) if eGFR 15–60 - Dabigatran: Avoid if eGFR \<30; 75 mg BID if 30–60 - Edoxaban: 30 mg daily if eGFR 15–50

**Diabetes Medications:** - **Metformin:** Avoid if eGFR \<30; reduce if 30–45 - **GLP-1 agonists:** Can continue but monitor for GI effects - **SGLT2i:** Continue for heart/kidney protection even in G3b–G4 - **Sulfonylureas:** Avoid (hypoglycemia risk); prefer GLP-1 or DPP-4 - **DPP-4i (Sitagliptin):** 25 mg daily if eGFR 30–50; 25 mg every 2 days if \<30

**Antibiotics:** - **Aminoglycosides:** Avoid or use extended-interval dosing (25 mg/kg once daily) with levels - **Fluoroquinolones:** 50% dose reduction if eGFR \<30 - **Trimethoprim-SMX:** Avoid if eGFR \<15 (hyperkalemia risk) - **Vancomycin:** Goal trough 15–20; check levels; may dose q24–48h in G4–G5

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## IV. Frailty Assessment in CKD Patients

### Why Frailty Matters in Elderly CKD

Frailty predicts mortality, disability, and poor outcomes independent of eGFR. Elderly CKD patients with frailty have markedly higher risk of: - Accelerated GFR decline - Acute illness and hospitalization - Falls and fractures - Progression to ESKD requiring dialysis - Death (within 1–2 years if severe frailty)

### Frailty Screening Tools

#### Simple Clinical Frailty Scale (CFS) — Grades 1–9

| Grade | Description | Clinical Context |
|----|----|----|
| **1–2** | Very fit / Well | Robust; pursue standard interventions |
| **3–4** | Managing well / Vulnerable | Mild impairment; watch for decline |
| **5–6** | Mildly frail / Moderately frail | ADL/IADL limitations; discuss goals |
| **7–8** | Severely frail / Very severely frail | Significant limitations; focus on comfort |
| **9** | Terminally ill | Palliative approach |

#### FRAIL Scale (Fried Risk Assessment of Instability for the Elderly) — 5 items

- **F:** Fatigue (self-reported weariness)
- **R:** Resistance (inability to walk up one flight of stairs)
- **A:** Ambulation (inability to walk one block)
- **I:** Illness (self-reported health = fair/poor)
- **L:** Loss of weight (\>5% unintentional weight loss)

*Score ≥3/5 = frail; 1–2 = pre-frail; 0 = robust*

### Integration into CKD Management

**Robust/Well elderly (CFS 1–2) with CKD:** - Pursue CV risk reduction, CKD progression prevention - Tight BP control, statin therapy, SGLT2i - Nephrology referral if CKD G4–G5 or rapid decline

**Vulnerable/Mildly frail (CFS 3–4) with CKD:** - Individualize treatment goals - Avoid aggressive BP targets; allow SBP 130–160 if tolerated - Annual functional and cognitive assessments - Simplify drug regimens - Consider late referral to nephrology (near ESKD) if dialysis planned

**Severely frail (CFS 6–8) with CKD:** - Goals-of-care discussions are **mandatory** - Avoid aggressive interventions - Focus on symptom management and quality of life - Conservative (non-dialysis) management often preferred

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## V. Polypharmacy and Deprescribing in Elderly CKD

### The Polypharmacy Burden in Elderly CKD

- Average elderly patient takes 5–7 medications
- Average CKD patient takes 8–10 medications
- Elderly with CKD takes 10–15 medications (and higher risk of adverse effects)

### Explicit Criteria for Medication Deprescribing

#### Medications Commonly Deprescribed in Elderly CKD:

| Drug | Reason for Deprescribing | Alternative/Action |
|----|----|----|
| **NSAIDs** | ↑ AKI, GI bleed risk; no benefit in CKD | Acetaminophen, topical NSAIDs, physical therapy |
| **Statins** (if age \>75, frail) | No CV benefit in primary prevention; ↑ myalgia | Continue only if secondary prevention or very robust |
| **Beta-blockers** (no CAD/HF) | No benefit if rate-controlled AFib; ↓ BP excessively | Taper; may improve functional capacity |
| **ACE-I/ARB** (if eGFR drop \>30% in 1 month) | Acute renal injury; hemodynamic changes | Discontinue; address underlying cause |
| **Loop diuretics** (chronic use, no edema/dyspnea) | Risk of dehydration, AKI, electrolyte abnormalities | D/C if euvolemic; switch to PRN dosing |
| **Anticholinergics** (diphenhydramine, oxybutynin) | Delirium, falls, urinary retention, ↓ cognition | Non-pharm alternatives; avoid |
| **PPI** (\>1 year continuous) | ↑ AKI, fractures, C. difficile; no data for long-term use | Taper and D/C if GERD controlled |
| **Sulfonylureas** | Hypoglycemia, worsening cognition | Switch to GLP-1, DPP-4i, or basal insulin only |
| **Benzodiazepines** | Falls, delirium, respiratory depression | Taper; non-pharm sleep/anxiety interventions |

### Deprescribing Strategy in Elderly CKD

1.  **Audit current medications** monthly in vulnerable/frail elderly
2.  **Ask “Why?”** for each medication: Is it still needed? Is dose appropriate?
3.  **Involve patient/family:** Frame as “cleaning up” medications to reduce side effects
4.  **Taper, don’t stop:** Most deprescribing requires slow taper to avoid rebound
5.  **Monitor after change:** Watch for rebound symptoms or new issues
6.  **Simplify:** Consolidate to once-daily or twice-daily dosing if possible

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## VI. Acute Kidney Injury in Elderly

### Epidemiology and Risk Factors

- **Incidence:** 50% higher in patients \>65; 70% higher in patients \>75
- **Mortality:** 2–3-fold higher in elderly with AKI (community-acquired) vs. younger patients
- **ICU AKI in elderly:** 30-day mortality 40–60% vs. 20–30% in younger

#### Age-Specific Risk Factors:

- Polypharmacy (NSAIDs, ACE-I, diuretics in combination)
- Baseline CKD (even mild; loss of renal reserve)
- Dehydration (reduced thirst sensation, frailty)
- Acute illness (infection, cardiac event) with reduced compensation
- Medications causing AKI (ACE-I with NSAIDs, contrast, aminoglycosides)
- Falls and rhabdomyolysis
- Urinary retention and obstructive uropathy

### Atypical Presentation of AKI in Elderly

Classic AKI presentation (**oliguria, dark urine, flank pain**) is often **absent** in elderly. Instead:

| Atypical Presentation | Classic Sign Usually Absent |
|----|----|
| **Non-oliguric AKI** (urine output 0.5–1 L/day) | Oliguria; GFR may be severely reduced |
| **Hypercreatininemia without oliguria** | Urine output \>1 L/day despite rising Cr |
| **Slowly rising creatinine** | Acute change may take 48–72 hours to manifest |
| **Confusion, weakness, falls** | Abdominal symptoms; may be mistaken for delirium |
| **Hyperkalemia without cardiac signs** | No peaked T-waves on EKG despite K \>6 |
| **Metabolic acidosis** | No GI symptoms; found incidentally on labs |

**Clinical Pearl:** Suspect AKI in any elderly patient with acute mental status change, weakness, or unexplained fall. Check creatinine, BUN, K+, and calculate FeNa or FEUrea.

### AKI Staging and Prognosis in Elderly

| KDIGO Stage | Cr Rise | Urine Output | 30-Day Mortality (Elderly) | Management Focus |
|----|----|----|----|----|
| **1** | 1.5–1.9× baseline or +0.3 | \<0.5 mL/kg/h × 6–12h | 5–10% | Identify cause; reverse causative agents |
| **2** | 2–2.9× baseline | \<0.5 mL/kg/h × ≥12h | 20–30% | Close monitoring; consider nephrology referral |
| **3** | ≥3× baseline or Cr ≥4 + acute rise ≥0.3 | \<0.3 mL/kg/h × ≥24h or anuria | 40–60% | RRT if indicated; aggressive management of complications |

### Management Principles in Elderly AKI

1.  **Volume assessment:** Use clinical exam (JVP, lung sounds, edema), not just labs
    - Avoid aggressive diuresis if hypovolemic (common in elderly)
    - Judicious fluid resuscitation if dehydrated (target MAP \>65 in sepsis)
2.  **Medication review:**
    - Hold ACE-I/ARB if hyperkalemia or rapid Cr rise
    - Avoid NSAIDs, contrast, aminoglycosides if possible
    - Continue SGLT2i if euvolemic (cardio-protective; no evidence of harm)
3.  **Target nutritional support:**
    - Elderly with AKI have ↑ protein catabolism
    - Provide 0.8–1.0 g/kg/day protein (not restriction)
    - Manage hyperkalemia aggressively (avoid K+ supplementation)
4.  **Dialysis decisions in elderly:**
    - Indication: K \>6.5 with EKG changes, metabolic acidosis pH \<7.15, severe uremia, volume overload
    - Discuss goals and outcomes; some elderly prefer conservative management
    - Intermittent hemodialysis, CRRT, or SCUF each have role depending on hemodynamic stability and goals

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## VII. CKD Progression Decisions in Elderly

### Key Question: Should We Slow CKD Progression in Elderly?

The answer depends on life expectancy, functional status, and patient goals.

#### Evidence for CKD Slowing Interventions in Elderly:

**SGLT2 Inhibitors:** - Benefit in elderly with CKD even without diabetes - Dapagliflozin (DAPA-CKD): 39% ↓ in GFR decline/ESRD/death in CKD; median age 61, 19% \>75 years - Empagliflozin (EMPA-KIDNEY): Similar benefit; ~23% were age \>75 - **Recommendation:** Continue SGLT2i in elderly CKD if tolerated and eGFR \>20

**ACE-I/ARB:** - Proven to slow progression in CKD + proteinuria - Less clear benefit in CKD without proteinuria - Benefit in elderly with hypertension and CKD - Risk: Hyperkalemia, acute decline in first 1 month (expected; usually stabilizes) - **Recommendation:** Continue if baseline UACR \>30 mg/g and K+ \<5.5

**GLP-1 Agonists (in CKD + diabetes):** - SGLT2i \> GLP-1 for renal protection, but GLP-1 also protective - Weight loss benefit helps CV disease in elderly diabetics - **Recommendation:** Use if tolerated; good CV/renal benefit

**Blood pressure targets:** Individualize treatment to standardized measurements, cardiovascular risk, frailty, symptoms, and patient priorities. SPRINT included adults aged 75 and older; age alone does not establish that a systolic target of 130–150 is safer for everyone. Monitor orthostasis, kidney function, and electrolytes. [SPRINT older-adult analysis](https://pubmed.ncbi.nlm.nih.gov/27195814/).

#### When CKD Progression Doesn’t Matter (Conservative Approach Preferred):

- **Life expectancy \<5 years** (frailty, advanced cancer, other terminal illness)
- **eGFR 15–30** with stable or slow decline (avoid unnecessary testing, specialist visits)
- **Very elderly (\>85) with multiple comorbidities** and declining functional status
- **Patient preference:** Some elderly choose to avoid medications and accept progression

#### Individualized Decision-Making Framework:

| Life Expectancy | eGFR | Proteinuria | Approach |
|----|----|----|----|
| \>10 years | \>30 | \+ (UACR \>30) | Optimize SGLT2i, ACEI/ARB, BP target SBP 130–140 |
| 5–10 years | 20–30 | ± | Selective use of SGLT2i; allow higher BP targets |
| \<5 years | \<20 | Any | Conservative management; focus on symptoms/goals |
| Very frail, any | Any | Any | Goals-of-care discussion; likely conservative |

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## VIII. Special Topics

### Anemia in Elderly CKD

- Higher hemoglobin targets may increase CV risk in elderly
- Target Hgb 10–11 g/dL is often safer than 11–12
- ESA dosing often lower needed due to reduced response; monitor for thromboembolic events

### Bone Disease in Elderly CKD

- Osteoporosis + CKD-MBD = very high fracture risk
- DEXA screening warranted if expected lifespan \>5 years
- Phosphate binders often unnecessary unless P \>5.5 mg/dL
- Avoid calcium-based binders if possible (cardiovascular risk)

### Cognitive Decline and CKD Progression

- Uremia, electrolyte abnormalities, anemia all contribute to delirium/cognitive decline
- Screen with MMSE or MoCA at CKD diagnosis; repeat annually
- May be reversible with medication adjustment or dialysis initiation

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## Practice Questions

1.  **An 78-year-old woman presents for routine visit. Labs show:** Serum Cr 1.2 mg/dL (baseline), eGFR 38 mL/min (CKD-EPI), no proteinuria, no hematuria. She is on lisinopril 10 mg daily, HCTZ 25 mg daily, and atorvastatin. No symptoms. Should you refer to nephrology?

    - 1.  Yes, she has CKD G3b
    - 1.  No, referral not indicated unless eGFR drops \>4 mL/min/year, develops proteinuria, or has symptoms
    - 1.  Yes, all CKD G3b patients should see a nephrologist
    - 1.  Yes, she is elderly and needs palliative care planning

    **Answer: B.** Stable CKD G3b without proteinuria or symptoms in an elderly patient does not require referral. Continue monitoring eGFR (annual labs) and optimize BP/CV risk factors. Referral only needed if: eGFR drops \>4 mL/min/year, UACR develops/worsens, or she develops symptoms or resistant hypertension.

2.  \*\*An 82-year-old man with CKD G4 (eGFR 22) and diabetes on lisinopril, metformin 1000 mg daily, and ibuprofen PRN for arthritis presents acutely with Cr rise from 3.5 to 4.8 mg/dL over 3 days, K+ 6.1 mEq/L, and confusion. You suspect AKI. First step?

    - 1.  Start dialysis immediately
    - 1.  Continue all home medications; increase monitoring
    - 1.  Stop lisinopril, metformin, NSAIDs; check orthostatic vitals and IV fluid status; obtain EKG for hyperkalemia
    - 1.  Refer to ICU for mechanical ventilation

    **Answer: C.** This elderly patient has AKI (likely NSAID + ACE-I + possible dehydration) with hyperkalemia. Immediate actions: (1) Discontinue ACE-I, metformin, NSAIDs; (2) assess volume status and renal perfusion; (3) obtain EKG (peaked T-waves risk); (4) treat hyperkalemia (calcium gluconate if EKG changes, insulin/glucose, kayexalate or SGLT2i if available). Confusion may improve with Cr stabilization.

3.  **You are deprescribing medications in a 79-year-old frail woman (CFS 7) with CKD G3b, stable CAD, and GERD. She is on:** aspirin 81 mg, atorvastatin 40 mg, omeprazole 20 mg daily, metoprolol 50 mg daily, lisinopril 5 mg daily. Which medication is the BEST candidate for deprescribing?

    - 1.  Aspirin (secondary prevention of MI)
    - 1.  Atorvastatin (for primary CV prevention; no recent MI)
    - 1.  Omeprazole (continuous \>1 year; ↑ AKI risk in CKD)
    - 1.  Metoprolol (rate control if AFib present)

    **Answer: C.** In a severely frail elderly patient with CKD, omeprazole is the best candidate for deprescribing because: (1) Evidence for long-term PPI use is weak; (2) PPIs increase AKI risk and bone loss in CKD; (3) If GERD is controlled, PPI can be tapered off. Taper over 2–4 weeks and monitor for rebound heartburn. Continue aspirin (secondary prevention), statin (secondary prevention), and BP meds (kidney protection).

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## Clinical Pearls Summary

- **Creatinine 1.0 in an 85-year-old ≠ normal GFR.** Always use CKD-EPI equation.
- **Elderly CKD without proteinuria, anemia, or symptoms may never need dialysis.** Stable observation is appropriate.
- **Frailty (not age alone) drives dialysis decision-making.** Use CFS or FRAIL scale.
- **AKI in elderly often presents atypically:** mental status change, weakness, falls. Suspect AKI first.
- **Deprescribe aggressively in frail elderly:** NSAIDs, long-term PPIs, statins (primary prevention), benzodiazepines.
- **SGLT2 inhibitors benefit elderly CKD** regardless of diabetes status; continue even in G4.
- **Conservative CKD management** (no slowing interventions) is appropriate if life expectancy \<5 years.

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## References

1.  Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117. [PubMed](https://pubmed.ncbi.nlm.nih.gov/38490803/)
2.  Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117. [PubMed](https://pubmed.ncbi.nlm.nih.gov/38490803/)
3.  SPRINT Research Group, Wright JT, Williamson JD, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015;373(22):2103. [PubMed](https://pubmed.ncbi.nlm.nih.gov/26551272/)
4.  Kramer A, Boenink R, Noordzij M, et al. The ERA-EDTA Registry Annual Report 2017: a summary. Clin Kidney J. 2020;13(4):693-709. [PubMed](https://pubmed.ncbi.nlm.nih.gov/32897277/)
5.  Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2:1–138. [Official KDIGO guideline](https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf).
6.  By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. [PubMed](https://pubmed.ncbi.nlm.nih.gov/37139824/)
7.  Inker LA, Eneanya ND, Coresh J, et al. New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race. N Engl J Med. 2021;385(19):1737-1749. [PubMed](https://pubmed.ncbi.nlm.nih.gov/34554658/)
8.  Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495. [PubMed](https://pubmed.ncbi.nlm.nih.gov/16129869/)
9.  Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-397. [PubMed](https://pubmed.ncbi.nlm.nih.gov/23764209/)
10. Deprescribing.org. Evidence-based deprescribing guidelines and algorithms. [Official repository](https://deprescribing.org/resources/deprescribing-guidelines-algorithms/).

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*Created for PA and medical student education. Consult clinical guidelines and supervising physician for patient care decisions.*

## Clinical Resources

- Clinical Review: Geriatric Nephrology Overview — Comprehensive clinical review with PubMed references


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