Renal vascular disease in the elderly

The aging of Western societies is causing a progressive increase in the number of patients over 65 starting dialysis. The EDTA Registry shows that in 1995 this section of the population represented nearly 45% of patients under dialysis, and the percentage is even higher in the USRDS at 48%, 20% of whom are over 75. These changes have not only been quantitative, but have also modified the causes of end-stage renal disease (ESRD). Diabetic nephropathy (DN) and renal vascular disease (RVD) account for more than 50% of all these causes, reaching 66% according to the latest USRDS calculations. According to these numbers, RVD represents 29% of all causes, the incidence varying with the age group, and has become the main cause of ESRD in the elderly (38% of all cases). Until a few years ago, RVD was synonymous with hypertension, but as the population ages, the range of diseases in this group is increasing. The main RVDs that cause ESRD in the elderly are: hypertensive RVD (nephrosclerosis), atheromatous RVD (either as ischemic atherosclerotic nephropathy or as atheroembolism), and acute occlusion of renal arteries (either bilateral or unilateral in single-kidney patients). The diagnosis of nephrosclerosis in the absence of histological confirmation is a presumed clinical diagnosis, made in most cases by exclusion, and is therefore clearly overestimated. On the other hand, atheromatous RVD is an underdiagnosed disease that is often overlooked. The prevalence, natural history, diagnosis and prognosis are discussed in this report.