Conventional dialysis in the elderly: How lenient should our guidelines be?

Abstract

There has been a dramatic, worldwide expansion in life expectancy across the last century. This has resulted in a progressively more elderly and comorbid population. It is increasingly recognized that healthcare in this group needs to move to the concept of “adding life to years”. Recognition and assessment of frailty is vital in changing our approach in elderly patients. Current guidelines in dialysis have a limited evidence base across all age groups, but particularly the elderly and serve them poorly. Moreover, the burden of guidelines for each comorbidity of the multimorbid patient is increasing and can be conflicting. Finally, there is increasing evidence relating to the harm associated with the delivery of conventional dialysis. In dialysis patients, frailty is the overwhelming determinant in relation to patient‐specific outcomes rather than modality of treatment; therefore, the focus should be on promoting quality of life. We need to focus on new priorities of care when we design guidelines “for people not diseases”. Patient‐centered goal‐directed therapy, arising from shared decision making between physician and patient, should allow adaption of the dialysis regime to maximize opportunities while minimizing treatment‐related morbidity and concentrating on alleviating symptoms.

Risk factors for mortality in elderly haemodialysis patients: a systematic review and meta-analysis

“…Elderly end-stage renal disease patients constitute an increasing fraction of patients on renal replacement therapy worldwide [ 1 ]. The mortality rate of elderly dialysis patients remains confusingly high in spite of recent technical advances, especially in those with a high rate of multimorbidity, muscular functional impairment, cognitive defects or falls [ 2 – 5 ].…”

Kidney supportive care: an update of the current state of the art of palliative care in CKD patients

“…While this is true across all patients on dialysis, the effects may be more pronounced in the frail elderly. These complications may accelerate any underlying cycle of frailty 87 . The commencement of hemodialysis (HD) is associated with increased levels of mortality, particularly in the elderly, along with loss of functional status in those who are most dependent 88 .…”

A Pragmatic Randomized clinical trial: twice-weekly vs. thrice-weekly Incident hemoDialysis in Elderly patients (PRIDE): study protocol

“…HD has potential advantages over conservative management or peritoneal dialysis in older adults [3,4]; however, guidelines for optimal HD for the elderly have not yet been established [5]. Typically, patients receive HD three times a week, with only a small proportion of patients receiving less frequent dialysis [6].…”