The number of patients aged 65 and older suffering from advanced chronic kidney disease and transitioning to end stage kidney disease (ESKD) increases progressively. Elderly patients however, often have poor outcomes, once hemodialysis (HD) is initiated, including high mortality within the first year, as well as fast cognitive and functional decline and diminished quality of life. The question is how we can smoothen this transition to ESKD in old patients who also exhibit much higher proportions of frailty, when compared to community-dwelling non-dialysis older adults and who are generally more vulnerable to invasive treatment such as kidney replacement therapy (KRT). To avoid early death and poor quality of life, a carefully prepared smooth transition should precede the initiation of treatment. This involves pre-dialysis physical and educational care, as well as mental and psychosocial preparedness of the patient to enable an informed and shared decision about the individual choice of treatment modality. Communication between health care professional and patient plays a pivotal role but can be challenging given the high proportion of cognitive impairment in this particular population. In order to practice patient-centered care, adapting treatment tailored to the individual patient should include comprehensive conservative care. However, structured treatment pathways including multidisciplinary teams for such conservative care are still rare and may be difficult to establish outside large cities. Generally, geriatric nephrology misses data on the comparative effectiveness of different treatment modalities in this population of old and very old age to base recommendations and decisions on better evidence.