Renal Replacement Therapy in Geriatric End-Stage Renal Disease Patients: A Clinical Approach

Abstract

The number of geriatric patients on dialysis is increasing. This is due to demographic factors, a wider acceptance of elderly patients on dialysis, and an earlier start of dialysis in this patient group. Recent studies have questioned the effect of dialysis on quality of life in elderly patients with severe comorbidity and showed limited survival in this specific patient group. Therefore, the decision whether or not to start dialysis may be a difficult one for both the clinician and patient. Risk scores can be of help in facilitating shared decision making, but not as a tool to withhold dialysis. However, in the elderly patient with severe comorbidity, conservative care can sometimes be a reasonable alternative to dialysis. In the process of shared decision making, a balance should be pursued between life expectancy and quality of life. If the decision to initiate dialysis is taken, choices have to be made regarding dialysis modality and treatment prescription. If adequate support is provided, assisted peritoneal dialysis can be an acceptable alternative to hemodialysis. Care for the elderly with end-stage renal disease should be undertaken by a multidisciplinary team with special dedication to a multidimensional approach in this population.

An Analysis of Elderly End-stage Chronic Kidney Disease Patients Who Did Not Undergo Renal Replacement Therapy in Japan

“…4,5 Although RRT undoubtedly improves the survival and quality of life greatly for numerous end-stage CKD patients, 8,10,12,13 there is no way to accurately estimate the survival time of the patients in the current study had they received RRT given the impossibility of performing a controlled trial despite the fact that uremia was the most prevalent cause of death among the current subjects. On the other hand, there is a growing recognition that RRT may not necessarily be the optimal choice in all the patients with end-stage CKD since the survival advantage of RRT is substantially diminished in patients with multiple comorbid conditions and a poor functional status, 2,3,8,10 while the bedridden status may have little impact on the survival of dialysis patients despite the poorer prognosis in dialysis patients compared with the Japanese general population. 4 The present study attempted to evaluate the clinical characteristics and survival of Japanese elderly patients with end-stage CKD that were not accepted to RRT.…”

“…1,2 Old age is no longer considered to be an absolute contraindication to commence periodic renal replacement therapy (RRT), 3 while recent studies have demonstrated the gradual increase in the mean age of new patients started on dialysis, as well as chronic dialysis patients overall. 1,4,5 Although several national registry databases have provided practical information regarding the outcomes and factors affecting the survival of patients commencing chronic dialysis treatment, they do not systemically follow patients with end-stage CKD who do not receive RRT.…”

Cycles, Arrows and Turbulence: Time Patterns in Renal Disease, a Path from Epidemiology to Personalized Medicine?

“…This is in some contrast to a non-dialysis population where especially in the older population mortality is associated with season [24]. Possibly, the reason for the pronounced seasonal mortality differences in younger dialysis patients is explained by a higher prevalence of frailty and hence an increased susceptibility to failure of homeostatic mechanisms as compared to the general population [36][37][38].…”

The role of peritoneal dialysis in modern renal replacement therapy

“…This difference was noted only in patients who had been on dialysis for more than a year, suggesting it was not due to lack of randomisation (although as discussed above there may be important psychological as well as physical differences between those patients who choose home-based and those who choose hospital-based dialysis treatments). The increased need for transport to the dialysis centre, which extends treatment times, and the higher incidence of complications such as hypotension on dialysis are likely to explain the greater impact of HD on the life of elderly patients 52. This effect is considerable; the number of hospital-free days of survival for one group of elderly patients on HD was not significantly better than the number of hospital-free days survived by a matched group receiving conservative care, despite a very significantly increased overall survival duration for those on HD (33.9 months vs 13.9 months) 53…”