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Cancer and chronic kidney disease prevalence both increase with age. As a consequence, physicians are more frequently encountering older people with cancer who need dialysis, or patients on dialysis diagnosed with cancer. Decisions in this context are particularly complex and multifaceted. In this Review, we aim to provide an overview of the key points to address when making a treatment strategy in these patients. We provide information on what happens if dialysis is not started or is stopped, and how physicians should deal with such patients. Informed decisions about dialysis require a personalised care plan that considers the prognosis and treatment options for each condition while also respecting patient preferences. The concept of prognosis should include quality-of-life considerations, functional status, and burden of care. Close collaboration between oncologists, nephrologists, and geriatricians is crucial to making optimal treatment decisions, and several tools are available for estimating cancer prognosis, prognosis of renal disease, and general age-related prognosis. Emerging evidence shows that these geriatric assessment tools, which measure degrees of frailty, are useful in patients with chronic kidney disease. In this Review, we try to hand tools to practising physicians, to guide decision making regarding the initiation and termination of dialysis in patients with advanced cancer.

Both acute kidney injury (AKI) and chronic kidney disease (CKD) are common in cancer patients and are associated with inferior outcome, higher mortality rates, longer hospital stays and higher costs. In the aging population, the prevalence of both cancer and end-stage renal disease increase and practitioners are faced with difficult decisions regarding initiation of anticancer therapy and renal replacement therapy (RRT). Recent studies have shown no survival benefit of RRT ⩾80 years or even ⩾70 years in combination with severe comorbidities. However cancer itself does not seem to be a determining factor for short-term survival outcome and should not be used as argument alone to withhold RRT. Several prognostic tools can be implemented to identify elderly patients at high risk of functional decline and mortality after initiation of RRT. Advanced care planning focusses on timely discussions between patients, family members and practitioners about the patient’s desires and treatment goals which can help them avoid decisional conflict at the end-of-life and improve the quality of life.

BACKGROUND AND AIMS Vaccination against COVID-19 is a promising strategy to reduce the risk for severe COVID-19. Patients on maintenance haemodialysis have a less robust immunoresponse than the general population. Triple vaccination might improve immunogenicity, and might benefit patients having a poor initial response. The aim of the current study was to evaluate the humoral response to heterologous (a combination of different vaccine types) versus homologous (three identical vaccines) triple vaccination against COVID-19. METHOD We analyzed serological response to homologous (3 times mRNA-based vaccine) versus heterologous (adenoviral vectored plus mRNA vaccines) triple regimens in samples from patients on maintenance dialysis (NCT04378686). We measured IgG anti–S (spike) SARS-CoV-2 antibody levels using the IgG II Quant assay (Abbott). Samples were collected between 6 and 12 weeks after both the second and the third vaccine dose. RESULTS A total of 302 patients received three vaccine doses. 94 patients received a heterologous regimen of the adenoviral vectored AZD1222 (2 doses) and the mRNA-based BNT162b2 (1 dose). The remaining 208 patients received a triple mRNA vaccine regimen of either BNT162b2 (n = 149) or mRNA-1273 (n = 59). Triple vaccine regimens resulted in significant elevation of anti-S titers, as compared with the conventional prime-boost (double) vaccination. A substantially and significantly larger fraction of patients reached the threshold for neutralizing antibodies after triple vaccination, as compared with after double vaccination. The yield of a third dose of mRNA-1273 is less than the yield of a third dose of BNT162b2. This, however, mainly reflects the initial significant better response to mRNA-1273. In multivariate analysis, a past episode of COVID-19 was a strong modulator of the response after double vaccination, and after triple vaccination. CONCLUSION Both heterologous and homologous triple vaccine regimens significantly augment the humoral response against SARS-CoV-2. The higher the ininitial response to the double prime-boost regimen, the lower the yield of a third vaccine dose. It seems prudent to prioritize vaccination of dialysis patients using mRNA-based vaccines when available.