What are the considerations for Renal Replacement Therapy (RRT) in an older adult patient with end-stage renal disease, diabetes, hypertension, and significant co-morbidities, such as cardiovascular disease, and how should treatment be individualized to improve quality of life and survival?

Ethical and Legal Issues in Renal Replacement Therapy for Older Adults with ESRD

Autonomy and Informed Decision-Making

Patients with end-stage renal disease must receive comprehensive, culturally appropriate education about all treatment options—including dialysis modalities, transplantation, and conservative management—delivered through both video and written materials at a 4th-6th grade reading level to ensure true informed consent regardless of health literacy. 1

• The decision aid must explicitly address potential benefits and trade-offs of each treatment selection, incorporating testimonials from demographically diverse patients describing both positive and negative experiences. 1
• Family members should be included in the educational process, as they often participate directly in treatment and provide essential support for patients' decisions. 1
• Educational programs must account for varying levels of health literacy, health numeracy, and cognitive function to ensure comprehension across all patient populations. 1

Clinical Vignette 1: Informed Consent Challenge

A 78-year-old woman with diabetes, hypertension, and mild dementia (MMSE 22/30) presents with eGFR 12 mL/min. Her daughter insists on hemodialysis, but the patient expresses fear of needles and prefers "no machines." How do you proceed?

Resolution: Conduct separate educational sessions with patient and family using visual aids and simplified materials. Assess the patient's decision-making capacity formally. If she retains capacity, her preference for conservative management or peritoneal dialysis must be honored over family wishes. Document capacity assessment and informed refusal thoroughly. 1

Age-Based Treatment Considerations

There should be no absolute upper age limit for excluding patients from renal replacement therapy when their overall health and life situation suggest transplantation or dialysis will be beneficial. 2

• Patients 60 years and older with ESRD who receive kidney transplants survive longer than dialysis patients with the same number of comorbid conditions. 2
• Advancing age mandates increased screening for cardiovascular disease and malignancies before initiating any form of RRT. 2
• Older transplant recipients (60-74 years) demonstrate better survival compared to similarly aged dialysis patients on the transplant waiting list. 2
• Cardiovascular disease and infections in the first few months post-transplant represent the leading causes of death in older renal transplant recipients. 2

Clinical Vignette 2: Age Discrimination Concern

A 72-year-old man with ESRD, well-controlled diabetes, and no cardiac disease requests transplant evaluation. The transplant surgeon states "he's too old" and refuses evaluation. Is this ethical?

Resolution: This constitutes age-based discrimination and violates established guidelines. The patient must receive formal transplant evaluation. His chronological age alone cannot exclude him—only specific contraindications (inadequate cardiopulmonary reserve, unsuitable anatomy, inability to tolerate immunosuppression) justify exclusion. 2

Withdrawal and Withholding of Dialysis

Patients retain the legal and ethical right to refuse dialysis initiation or request dialysis withdrawal at any time, and clinicians must honor these decisions after ensuring the patient understands the consequences. 3

• Life expectancy estimates should guide treatment intensity discussions, particularly when considering whether aggressive RRT aligns with patient goals. 3
• Treatment decisions that contradict practice guidelines may be appropriate for certain patients when individualized assessment reveals limited benefit or excessive burden. 3
• Conservative management without dialysis represents a legitimate treatment option that should be presented alongside RRT modalities. 3, 4

Clinical Vignette 3: Dialysis Withdrawal Request

An 82-year-old man on hemodialysis for 2 years with progressive dementia, recurrent hospitalizations, and declining functional status tells you "I'm done with dialysis. I want to stop." His family threatens legal action if you "let him die."

Resolution: Assess decision-making capacity. If he retains capacity, his autonomous decision to withdraw dialysis must be honored despite family objections. Arrange palliative care consultation, discuss expected timeline (typically 7-14 days), manage symptoms aggressively, and document thoroughly. If he lacks capacity, convene family meeting to discuss his previously stated values and whether continued dialysis aligns with his goals. 3

Resource Allocation and Access to Care

Most heart failure clinical trials have historically excluded patients with end-stage renal disease and those receiving renal replacement therapy, creating an evidence gap that complicates treatment decisions and raises justice concerns. 2

• Patients receiving RRT should not be automatically excluded from clinical trials via natriuretic peptide enrollment criteria, as this perpetuates therapeutic nihilism. 2
• Dependence on RRT for volume removal makes acute decompensated heart failure difficult to ascertain due to chronically elevated natriuretic peptide concentrations. 2

Clinical Vignette 4: Trial Exclusion Dilemma

A 68-year-old woman on peritoneal dialysis with heart failure with reduced ejection fraction qualifies for a promising heart failure medication trial but is excluded because she receives RRT. She asks why she cannot participate.

Resolution: Acknowledge that systematic exclusion of RRT patients from trials represents an ethical problem that limits evidence generation for this vulnerable population. Advocate with the trial sponsor for inclusion or seek alternative trials. Consider off-label use of the investigational agent if safety data support it, with informed consent about limited evidence. 2

Quality of Life vs. Quantity of Life

For older adults with multiple comorbidities, treatment selection must prioritize quality of life over survival duration, as dialysis may prolong life without improving—or while worsening—functional status and symptom burden. 3, 5

• Elderly ESRD patients experience substantially reduced life expectancy compared with age-matched counterparts from the general population, with cardiac disease as the leading cause of death. 5
• Patients over 60 have longer initial hospitalizations post-transplant but fewer acute rejection episodes, with self-reported quality of life similar to age-matched non-transplant controls. 2
• The substantial mortality and comorbidity in elderly ESRD populations makes their management an ongoing challenge requiring individualized approaches. 5

Clinical Vignette 5: Quality vs. Quantity Conflict

A 76-year-old man with ESRD, severe COPD (home O2), and recent stroke with residual hemiparesis is hospitalized with uremic symptoms. Nephrology recommends urgent hemodialysis initiation. He states "I just want to be comfortable at home, not tied to a machine three times weekly."

Resolution: Respect his preference for conservative management. Arrange palliative nephrology consultation to manage uremic symptoms (nausea, pruritus, restless legs) medically. Provide dietary counseling to minimize uremic toxin accumulation. Establish hospice services. His choice prioritizes quality over quantity and represents a legitimate treatment pathway. 3, 5

Cardiovascular Disease Management in RRT Patients

Older adults with cardiorenal syndrome requiring renal replacement therapy face particularly high mortality risk, and when RRT becomes necessary, Continuous Renal Replacement Therapy (CRRT) is strongly preferred over intermittent hemodialysis for superior hemodynamic stability. 6, 7

• Aggressive loop diuretic therapy represents first-line management for cardiorenal syndrome, often requiring combination therapy with thiazide diuretics to overcome diuretic resistance. 6, 7
• ACE inhibitors/ARBs and beta-blockers should be continued in patients with reduced ejection fraction while monitoring renal function closely, never using diuretics as monotherapy. 6, 7
• The risk of persistent congestion outweighs transient worsening of renal function, so necessary diuretic therapy should not be withheld for modest creatinine elevations. 7

Clinical Vignette 6: Cardiorenal Syndrome Management

A 70-year-old woman with heart failure (EF 25%) and CKD stage 4 (eGFR 22) presents with acute decompensation. Creatinine rises from 2.1 to 2.8 mg/dL after aggressive diuresis. Cardiology wants to stop diuretics; nephrology recommends urgent dialysis.

Resolution: Continue aggressive diuresis despite rising creatinine, as persistent congestion poses greater immediate risk than transient azotemia. Monitor for signs of hypoperfusion. If volume overload persists despite maximal medical therapy, initiate CRRT rather than intermittent hemodialysis for better hemodynamic tolerance. The creatinine elevation likely reflects improved forward flow rather than true kidney injury. 6, 7

Medication Management and Nephrotoxin Avoidance

Immediately discontinue the "triple whammy" combination of NSAIDs, diuretics, and ACE inhibitors/ARBs in patients with volume depletion, as this combination more than doubles the risk of developing acute kidney injury. 8

• All medications that renal transplant candidates require should be carefully reviewed in anticipation of possible drug interactions if continued post-transplant. 2
• Avoiding critical drug interactions in the early post-transplant period prevents over-immunosuppression (increased infection/cancer risk), under-immunosuppression (increased rejection risk), and nephrotoxicity. 2

Clinical Vignette 7: Medication-Induced AKI

An 80-year-old man on lisinopril and furosemide for hypertension develops gastroenteritis. His primary care physician prescribes ibuprofen for abdominal cramping. He presents 3 days later with AKI (creatinine 4.2 mg/dL from baseline 1.4 mg/dL).

Resolution: This represents preventable iatrogenic AKI from the triple whammy. Immediately stop all three medications. Administer 0.9% normal saline 1 liter IV over the first hour, then continue isotonic saline at slower rate for 24-48 hours. Monitor hourly urine output (target >100-150 mL during first 6 hours). Check serial creatinine every 12-24 hours. Renal function should improve within 24-48 hours with appropriate fluid resuscitation. 8

Timing of RRT Initiation

Unresolved issues remain for elderly ESRD patients regarding optimal timing of dialysis initiation, requiring individualized assessment of uremic symptoms, volume status, and patient preferences rather than eGFR thresholds alone. 5

• Early referral to nephrology and patient education through multidisciplinary renal management programs impact patient outcomes and RRT modality choice. 9
• Pre-emptive transplantation before dialysis requirement represents the ideal scenario when feasible. 4

Clinical Vignette 8: Early vs. Late Dialysis Initiation

A 74-year-old asymptomatic woman with eGFR 8 mL/min is told by her nephrologist "you need to start dialysis now." She feels well, has no edema, normal potassium, and asks "why start if I feel fine?"

Resolution: Asymptomatic patients with very low eGFR do not require immediate dialysis initiation based on laboratory values alone. Monitor closely for development of uremic symptoms (nausea, anorexia, pruritus, altered mental status), volume overload, refractory hyperkalemia, or metabolic acidosis. Provide intensive dietary counseling. Initiate dialysis when symptoms develop or life-threatening complications arise, not based on arbitrary eGFR cutoffs. 5

Modality Selection: Hemodialysis vs. Peritoneal Dialysis

Unless obvious contraindications exist, patient preference should determine dialysis modality selection after comprehensive education, as there is no conclusive evidence that either modality is superior. 4

• Peritoneal dialysis does not provide the same level of fluid and toxin removal as hemodialysis, and many patients will require transfer to hemodialysis within 2-3 years as PD gradually loses effectiveness. 4
• The form of RRT instituted should primarily be based on patient preference following an individually tailored education program that accounts for comorbidities and contraindications. 4

Clinical Vignette 9: Modality Selection Pressure

A 69-year-old man with ESRD prefers peritoneal dialysis for lifestyle flexibility. His nephrologist strongly pushes hemodialysis, stating "PD won't work for you—you're too big and it will fail anyway."

Resolution: This represents inappropriate paternalism. Absent specific contraindications (inadequate peritoneal membrane function, inability to perform exchanges, lack of space for supplies, severe obesity with abdominal wall hernias), the patient's informed preference for PD must be honored. Arrange PD training. Counsel that transition to HD may become necessary in 2-3 years, but this does not preclude initial PD trial. 4

Transplant Candidacy in Older Adults

Advancing age increases the need to periodically reevaluate patients on the transplant waiting list, as cardiovascular disease progression and new malignancies may develop that alter candidacy. 2

• Only 9% of patients on the UNOS waiting list are 65 years or older, despite nearly 50% of all ESRD patients being over 50 years of age, suggesting systematic under-referral. 2
• Assessment for transplantation requires consideration of suitability for general anesthesia, adequate blood supply and urinary drainage, space for a kidney, and candidacy for long-term immunosuppression. 4
• Ninety percent of live donor transplant recipients in the UK were alive 10 years later, compared with 74% of deceased donor recipients. 4

Clinical Vignette 10: Transplant Listing Controversy

A 67-year-old woman with ESRD from hypertension, well-controlled diabetes (A1C 6.8%), and normal cardiac stress test requests transplant evaluation. She has a willing living donor (her daughter). The transplant center declines evaluation citing "limited organ availability for younger patients."

Resolution: This represents unethical age-based rationing. She meets medical criteria and has a living donor, eliminating organ scarcity concerns. She must receive formal evaluation. Her outcomes would likely be excellent given absence of severe cardiac disease and availability of living donor. Advocate for her evaluation or refer to another transplant center. 2, 4

Documentation and Legal Protection

Thorough documentation of capacity assessments, informed consent discussions, treatment preferences, and family meetings provides essential legal protection when honoring patient autonomy in RRT decisions. 3

• Document specific elements discussed: treatment options presented, risks and benefits explained, patient's understanding demonstrated, questions answered, and decision reached. 1
• When patients lack capacity, document surrogate decision-maker identification, patient's previously stated values, and how treatment recommendations align with those values. 3

Clinical Vignette 11: Documentation Failure

An 85-year-old man with advanced dementia on hemodialysis becomes increasingly agitated during treatments. His healthcare proxy (son) requests dialysis discontinuation. No advance directive exists. The dialysis unit refuses without "proof" of the patient's wishes.

Resolution: The healthcare proxy has legal authority to make decisions when the patient lacks capacity. Document: (1) formal capacity assessment showing patient cannot participate in decisions, (2) healthcare proxy documentation, (3) discussion with proxy about patient's previously stated values and goals, (4) how dialysis withdrawal aligns with those values, (5) proxy's informed decision to withdraw. Proceed with withdrawal and palliative care. 3

Racial and Ethnic Considerations

Black patients should have natriuretic peptide enrollment thresholds lowered by 20-30% in clinical trials to avoid exclusion, as they have historically lower BNP and NT-proBNP concentrations. 2

• The need for different cutoff values based on race may be more relevant in prevention studies than trials of patients with established disease. 2
• Culturally appropriate patients and families should be incorporated into educational materials to ensure relevance across diverse populations. 1

Conservative Management as Legitimate Option

Conservative management without dialysis represents an evidence-based treatment pathway that should be presented alongside RRT options, particularly for patients with limited life expectancy or high symptom burden from dialysis. 3, 5

• This approach focuses on symptom management, dietary modifications, and supportive care rather than life prolongation through RRT. 3
• Palliative nephrology consultation can optimize uremic symptom control without dialysis. 3

Clinical Vignette 12: Conservative Management Choice

An 88-year-old woman with ESRD, severe dementia (nonverbal), recurrent aspiration pneumonia, and pressure ulcers is referred for dialysis initiation. Her daughter asks "is there another option besides dialysis?"

Resolution: Conservative management represents the most appropriate option given her advanced dementia, poor functional status, and limited life expectancy. Dialysis would impose significant burden without meaningful benefit. Arrange palliative care and hospice services. Focus on comfort measures, dietary liberalization, and symptom management. This approach honors her dignity and avoids futile intervention. 3, 5