From the Guidelines
For patients over 80 with end-stage renal disease, conservative kidney management without dialysis is a reasonable alternative to dialysis, focusing on symptom control and may provide similar quality of life with less treatment burden, as evidenced by recent studies 1. When considering dialysis in patients over 80, it is essential to weigh the potential benefits against the significant concerns about quality of life and survival.
- The available modalities for dialysis are hemodialysis (typically three sessions weekly, 3-4 hours each) or peritoneal dialysis.
- Important considerations include that elderly patients on dialysis experience high symptom burden, with 20-30% dying within the first year of treatment.
- They also face more complications including hypotension during treatment, vascular access problems, and higher hospitalization rates.
- Functional status often declines after dialysis initiation, with many elderly patients losing independence. The decision to initiate dialysis should be individualized based on the patient's overall health status, comorbidities, functional status, and personal preferences, as recommended by recent guidelines 1.
- Geriatric assessment including evaluation of frailty, cognitive function, and social support is essential before making this decision.
- Early palliative care involvement can benefit patients regardless of the chosen treatment path, with a focus on reducing symptom burden and suffering and improving quality of life and well-being 1. In patients with severely limited life expectancy, low quality of life, refractory pain, or progressive deterioration due to an untreatable disease, discontinuation of dialysis or avoidance of dialysis treatment should be discussed as part of shared-decision-making, with integrated palliative care offered to all patients who are stopping or deciding not to undergo dialysis 1.
From the Research
Benefits and Harms of Dialysis in Patients over 80 with ESRD
- The decision to initiate dialysis in patients over 80 with end-stage renal disease (ESRD) should be made on a case-by-case basis, considering the patient's unique goals, priorities, and clinical situation 2.
- Observational data suggests that dialysis may not provide a survival benefit for older adults with poor mobility and high levels of comorbidity 2.
- A study of patients aged 80 years or older starting dialysis found a median survival of 46.5 months, with 1- and 5-year survival rates of 78.5% and 38.3%, respectively 3.
- Factors predicting poorer survival in this population include Caucasoid ethnicity and low serum albumin levels at dialysis initiation 3.
- The choice of dialysis modality and vascular access should be made with consideration of the patient's end-stage kidney disease Life-Plan, life expectancy, and potential complications 4.
- Frailty and functional status are important considerations in the decision to initiate dialysis, as they are associated with poor outcomes in elderly patients with CKD 5.
- Prognostic tools have been developed to estimate the rate of CKD progression and risk of mortality after dialysis initiation in elderly patients 5.
- The decision to initiate dialysis should take into account the patient's quality of life, as well as their preferences and those of their caregivers 2, 5.
Considerations for Dialysis Initiation
- The patient's pattern of renal function loss over time, in relation to their underlying comorbidities, can serve as a guide to the probability of a future dialysis requirement 2.
- Early and repeat shared decision-making conversations between healthcare providers, patients, and their families are essential to optimize care for this population 2.
- A comprehensive approach to patient care, involving the integration of nephrology, geriatric, and palliative medicine practices, is necessary to address the complex needs of elderly patients with ESRD 6.
- The potential advantages and disadvantages of dialysis therapy should be considered in conjunction with each patient's unique goals and priorities 2.