Renal replacement therapy in the elderly population

Abstract

ESRD has become an important problem for elderly patients. The segment of the ESRD population age 65 years or older has grown considerably, and this growth is expected to accelerate in coming years. Nephrologists caring for the elderly with advanced kidney disease will encounter patients with comorbid conditions common in younger patients, as well as physical, psychological, and social challenges that occur with increased frequency in the aging population. These challenging factors must be addressed to help inform decisions regarding the option to initiate dialysis, the choice of dialysis modality, whether to pursue kidney transplantation, and end-of-life care. This article will highlight some common problems encountered by elderly patients with ESRD and review data on the clinical outcomes of elderly patients treated with different modalities of dialysis, outcomes of kidney transplantation in the elderly, and nondialytic management of CKD stage 5.

Figure 1.

Six-month prognostic risk score in patients ≥75 years who initiate dialysis. Adapted from a prognostic model developed and validated by Couchoud et al. (30) using the French Renal Epidemiology and Information Network registry to predict 6-month mortality in ESRD patients ≥75 years who initiated dialysis. BMI, body mass index.

Figure 2.

Approach to the elderly patient with ESRD. The model uses such factors as cognitive impairment, functional impairment, and the severity of comorbid conditions to help guide the clinical thought process. The model emphasizes circumstances in which nondialytic management, including palliative care, may be appropriate, as well as the need for continual assessment of patients on dialysis to determine whether changes requiring reassessment of the appropriateness of continuing renal replacement therapy have occurred. ECD, expanded-criteria donor; HD, hemodialysis; PD, peritoneal dialysis.