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Renal function and delirium in older fracture patients: different information from different formulas?

Published:November 08, 2019DOI:https://doi.org/10.1016/j.ejim.2019.10.022

      Abstract

      Objectives

      the association between renal function and delirium has not been investigated in older fracture patients. Creatinine is frequently low in these subjects, which may influence the association between delirium and renal function as estimated with creatinine-based formulas. Cystatin C could be a more reliable filtration marker in these patients.

      Aim

      to confirm the association between renal function and delirium in older fracture patients comparing creatinine- and cystatin-based estimated glomerular filtration rate (eGFR)

      Methods

      patients aged 65+ requiring surgery for traumatic bone fractures were included. Six equations were used to calculate eGFR, based on serum creatinine and/or cystatin C obtained within 24 h of admission: Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology (CKD-EPIcr, CKD-EPIcys, CKD-EPIcr-cys) and Berlin Initiative Study equations (BIS-1, BIS-2). Delirium was identified with a chart-based method.

      Results

      571 patients (mean age 83) were enrolled. Delirium occurred in the 34% and was associated with a lower eGFR regardless of the equation used. In a multivariable model, the association between moderate renal impairment (eGFR 30–60 ml/min/1.73 m2) and delirium remained significant in patients aged 75–84 and only when estimated with cystatin-based or BIS-1 equations. Only dementia was significantly associated with delirium in subjects 85+.

      Conclusions

      in older fracture patients, moderate renal impairment was independently associated with delirium only among subjects aged 75–84, when eGFR was estimated with cystatin-based or BIS 1 equations, and not with the most commonly used equations (MDRD, CKD-EPIcr).

      Keywords

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      References

        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders.
        5th ed. Arlington: American Psychiatric Association, 2013
        • Oh ES
        • Fong TG
        • Hshieh TT
        • Inouye SK
        Delirium in older persons: advances in diagnosis and treatment.
        JAMA. 2017; 318: 1161-1174
        • Wagner P
        • Fuentes P
        • Diaz A
        • Martinez F
        • Amenabar P
        • Schweitzer D
        • et al.
        Comparison of complications and length of hospital stay between orthopedic and orthogeriatric treatment in elderly patients with a hip fracture.
        Geriatr Orthop Surg Rehabil. 2012; 3: 55-58
        • Morandi A
        • Di Santo SG
        • Zambon A
        • Mazzone A
        • Cherubini A
        • Mossello E
        • et al.
        Delirium, dementia and in-hospital mortality: the results from the Italian Delirium Day 2016, a national multicenter study.
        J Gerontol A Biol Sci Med Sci. 2019; 74: 910-916
        • Bellelli G
        • Mazzola P
        • Morandi A
        • Bruni A
        • Carnevali L
        • Corsi M
        • et al.
        Duration of postoperative delirium is an independent predictor of 6-month mortality in older adults after hip fracture.
        J Am Geriatr Soc. 2014; 62: 1335-1340
        • Pisani MA
        • Murphy TE
        • Van Ness PH
        • Araujo KL
        • Inouye SK
        Characteristics associated with delirium in older patients in a medical intensive care unit.
        Arch Intern Med. 2007; 167: 1629-1634
        • McQuillan R
        • Jassal SV.
        Neuropsychiatric complications of chronic kidney disease.
        Nat Rev Nephrol. 2010; 6: 471-479
        • Da Matta SM
        • Janaina Matos M
        • Kummer AM
        • Barbosa IG
        • Teixeira AL
        • Silva AC
        Cognitive alterations in chronic kidney disease: an update.
        J Bras Nefrol. 2014; 36: 241-245
        • Sato T
        • Hatakeyama S
        • Okamoto T
        • Yamamoto H
        • Hosogoe S
        • Tobisawa Y
        • et al.
        Slow gait speed and rapid renal function decline are risk factors for postoperative delirium after urological surgery.
        PLoS One. 2016; 11e0153961
        • Siew ED
        • Fissell WH
        • Tripp CM
        • Blume JD
        • Wilson MD
        • Clark AJ
        • et al.
        Acute kidney injury as a risk factor for delirium and coma during critical illness.
        Am J Respir Crit Care Med. 2017; 195: 1597-1607
      1. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. Epub ahead of print2019.

        • González-Montalvo JI
        • Alarcón T
        • Gotor P
        • Queipo R
        • Velasco R
        • Hoyos R
        • et al.
        Prevalence of sarcopenia in acute hip fracture patients and its influence on short-term clinical outcome.
        Geriatr Gerontol Int. 2016; 16: 1021-1027
        • Kidney Disease
        Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
        Kidney Int Suppl. 2013; 3: 1-150
        • Drevet S
        • Bioteau C
        • Mazière S
        • Couturier P
        • Merloz P
        • Tonetti J
        • et al.
        Prevalence of protein-energy malnutrition in hospital patients over 75 years of age admitted for hip fracture.
        Orthop Traumatol Surg Res. 2014; 100: 669-674
        • Van Pottelbergh G
        • Vaes B
        • Adriaensen W
        • Matheï C
        • Legrand D
        • Wallemacq P
        • et al.
        The glomerular filtration rate estimated by new and old equations as a predictor of important outcomes in elderly patients.
        BMC Med. 2014; 12: 27
        • Shlipak MG
        • Matsushita K
        • Ärnlöv J
        • Inker LA
        • Katz R
        • Polkinghorne KR
        • et al.
        CKD Prognosis Consortium. Cystatin C versus creatinine in determining risk based on kidney function.
        N Engl J Med. 2013; 369: 932-943
        • Canales MT
        • Blackwell T
        • Ishani A
        • et al.
        Estimated GFR and mortality in older men: are all eGFR formulae equal?.
        Am J Nephrol. 2016; 43: 325-333
        • Fossati P
        • Prencipe L
        • Berti G
        Enzymatic creatinine assay: a new colorimetric method based on hydrogen peroxide measurement.
        Clin Chem. 1983; 29: 1494-1496
        • Levey AS
        • Bosch JP
        • Lewis JB
        • Greene T
        • Rogers N
        • Roth D
        A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group.
        Ann Intern Med. 1999; 130: 461-470
        • Levey AS
        • Stevens LA
        • Schmid CH
        • Zhang YL
        • 3rd Castro AF
        • Feldman HI
        • et al.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Schaeffner ES
        • Ebert N
        • Delanaye P
        • Frei U
        • Gaedeke J
        • Jakob O
        • et al.
        Two novel equations to estimate kidney function in persons aged 70 years or older.
        Ann Intern Med. 2012; 157: 471-481
        • Inker LA
        • Schmid CH
        • Tighiouart H
        • Eckfeldt JH
        • Feldman HI
        • Greene T
        • et al.
        Estimating glomerular filtration rate from serum creatinine and cystatin C.
        N Engl J Med. 2012; 367: 20-29
        • Inouye SK
        • Leo-Summers L
        • Zhang Y
        • Bogardus Jr, ST
        • Leslie DL
        • Agostini JV
        A chart-based method for identification of delirium: validation compared with interviewer ratings using the confusion assessment method.
        J Am Geriatr Soc. 2005; 53: 312-318
        • Kuhn E
        • Du X
        • McGrath K
        • Coveney S
        • O'Regan N
        • Richardson S
        • et al.
        Validation of a consensus method for identifying delirium from hospital records.
        PLoS One. 2014 Nov 4; 9e111823
        • Mossello E
        • Pieraccioli M
        • Nesti N
        • Bulgaresi M
        • Lorenzi C
        • Caleri V
        • et al.
        Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs.
        JAMA Intern Med. 2015; 175: 578-585
        • Elia M.
        Screening for malnutrition: a multidisciplinary responsibility.
        Development and use of the Malnutrition Universal Screening Tool (‘MUST’) for adults. Redditch: BAPEN, 2003
        • Bugnicourt JM
        • Godefroy O
        • Chillon JM
        • Choukroun G
        • Massy ZA
        Cognitive disorders and dementia in CKD: the neglected kidney-brain axis.
        J Am Soc Nephrol. 2013; 24: 353-363
        • Singh NP
        • Sahni V
        • Wadhwa A
        • Garg S
        • Bajaj SK
        • Kohli R
        • et al.
        Effect of improvement in anemia on electroneurophysiological markers (P300) of cognitive dysfunction in chronic kidney disease.
        Hemodial Int. 2006; 10: 267-273
        • Sánchez JC
        • Ospina JP
        • González MI
        Association between leptin and delirium in elderly inpatients.
        Neuropsychiatr Dis Treat. 2013; 9: 659-666
        • Bakker RC
        • Osse RJ
        • Tulen JH
        • Kappetein AP
        • Bogers AJ
        Preoperative and operative predictors of delirium after cardiac surgery in elderly patients.
        Eur J Cardiothorac Surg. 2012; 41: 544-549
        • van Meenen LC
        • van Meenen DM
        • de Rooij SE
        • ter Riet G
        Risk prediction models for postoperative delirium: a systematic review and meta-analysis.
        J Am Geriatr Soc. 2014; 62: 2383-2390
        • Kalisvaart KJ
        • Vreeswijk R
        • de Jonghe JF
        • van der Ploeg T
        • van Gool WA
        • Eikelenboom P
        • et al.
        Risk factors and prediction of postoperative delirium in elderly hip-surgery patients: implementation and validation of a medical risk factor model.
        J Am Geriatr Soc. 2006; 54: 817-822
        • Smith TO
        • Cooper A
        • Peryer G
        • Griffiths R
        • Fox C
        • Cross J
        • et al.
        Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis.
        Int J Geriatr Psychiatry. 2017; 32: 386-396
        • Segarra A
        • de la Torre J
        • Ramos N
        • Quiroz A
        • Garjau M
        • Torres I
        • et al.
        Assessing glomerular filtration rate in hospitalized patients: a comparison between CKD-EPI and four cystatin C-based equations.
        Clin J Am Soc Nephrol. 2011; 6: 2411-2420
        • Díaz de Bustamante M
        • Alarcón T
        • Menéndez-Colino R
        • Ramírez-Martín R
        • Otero Á
        • González-Montalvo JI
        Prevalence of malnutrition in a cohort of 509 patients with acute hip fracture: the importance of a comprehensive assessment.
        Eur J Clin Nutr. 2018; 72: 77-81
        • Dharnidharka VR
        • Kwon C
        • Stevens G
        Serum cystatin C is superior to serum creatinine as a marker of kidney function: a meta-analysis.
        Am J Kidney Dis. 2002; 40: 221-226
        • Vega A
        • García de Vinuesa S
        • Goicoechea M
        • Verdalles U
        • Martínez-Pueyo ML
        • Chacón A
        • et al.
        Evaluation of methods based on creatinine and cystatin C to estimate glomerular filtration rate in chronic kidney disease.
        Int Urol Nephrol. 2014; 46: 1161-1167
        • Lopes MB
        • Araújo LQ
        • Passos MT
        • Nishida SK
        • Kirsztajn GM
        • Cendoroglo MS
        • et al.
        Estimation of glomerular filtration rate from serum creatinine and cystatin C in octogenarians and nonagenarians.
        BMC Nephrol. 2013; 14: 265
        • Kilbride HS
        • Stevens PE
        • Eaglestone G
        • Knight S
        • Carter JL
        • Delaney MP
        • et al.
        Accuracy of the MDRD (Modification of Diet in Renal Disease) study and CKD-EPI (CKD Epidemiology Collaboration) equations for estimation of GFR in the elderly.
        Am J Kidney Dis. 2013; 61: 57-66
        • Murata K
        • Baumann NA
        • Saenger AK
        • Larson TS
        • Rule AD
        • Lieske JCR
        elative performance of the MDRD and CKD-EPI equations for estimating glomerular filtration rate among patients with varied clinical presentations.
        Clin J Am Soc Nephrol. 2011; 6: 1963-1972
        • Galyfos GC
        • Geropapas GE
        • Sianou A
        • F4 Sigala
        • Filis K
        Risk factors for postoperative delirium in patients undergoing vascular surgery.
        J Vasc Surg. 2017; 66: 937-946
        • Alvarez-Perez FJ
        • Paiva F.
        Prevalence and risk factors for delirium in acute stroke patients. A retrospective 5-years clinical series.
        J Stroke Cerebrovasc Dis. 2017; 26: 567-573
        • Dittrich T
        • Tschudin-Sutter S
        • Widmer AF
        • Rüegg S
        • Marsch S
        • Sutter R
        Risk factors for new-onset delirium in patients with bloodstream infections: independent and quantitative effect of catheters and drainages-a four-year cohort study.
        Ann Intensive Care. 2016; 6: 104
        • Gruber-Baldini AL
        • Hosseini M
        • Orwig D
        • Grattan L
        • Chiles Shaffer N
        • Hochberg M
        • et al.
        Cognitive differences between men and women who fracture their hip and impact on six-month survival.
        J Am Geriatr Soc. 2017; 65: e64-e69
        • Seitz DP
        • Adunuri N
        • Gill SS
        • Rochon PA
        Prevalence of dementia and cognitive impairment among older adults with hip fractures.
        J Am Med Dir Assoc. 2011; 12: 556-564
        • Zerah L
        • Cohen-Bittan J
        • Raux M
        • Meziere A
        • Tourette C
        • Neri C
        • et al.
        Association between cognitive status before surgery and outcomes in elderly patients with hip fracture in a dedicated orthogeriatric care pathway.
        J Alzheimers Dis. 2017; 56: 145-156
        • Okura T
        • Jotoku M
        • Irita J
        • Enomoto D
        • Nagao T
        • Desilva VR
        • et al.
        Association between cystatin C and inflammation in patients with essential hypertension.
        Clin Exp Nephrol. 2010; 14: 584-588
        • Hedström M
        • Ljungqvist O
        • Cederholm T
        Metabolism and catabolism in hip fracture patients: nutritional and anabolic intervention–a review.
        Acta Orthop. 2006; 77: 741-747
        • Macdonald A
        • Adamis D
        • Treloar A
        • Martin F
        C-reactive protein levels predict the incidence of delirium and recovery from it.
        Age Ageing. 2007; 36: 222-225
        • Schanz M
        • Pannes D
        • Dippon J
        • Wasser C
        • Alscher MD
        • Kimmel M
        The influence of thyroid function, inflammation, and obesity on risk prediction of acute kidney injury by cystatin c in the emergency department.
        Kidney Blood Press Res. 2016; 41: 604-613
        • Pendlebury ST
        • Lovett N
        • Smith SC
        • Cornish E
        • Mehta Z
        • Rothwell PM
        Delirium risk stratification in consecutive unselected admissions to acute medicine: validation of externally derived risk scores.
        Age Ageing. 2016; 45: 60-65