Renal Replacement Therapy For Elderly Patients with ESKD Through Shared Decision-Making

Abstract

The incidence and prevalence of end-stage kidney disease (ESKD) in Korea are increasing, and ESKD constitutes a very important medical and social issue. Elderly dialysis patients have the highest risk of early mortality within 3 months after initiating dialysis, and geriatric syndromes such as aging, frailty, functional impairment, and cognitive impairment are crucial for the prognosis of elderly patients. Shared decision-making (SDM) is an approach through which clinicians and patients can achieve informed preferences, thereby yielding better clinical outcomes and quality of life. Through SDM-based, close consultation among patients, families, and healthcare providers, an ESKD Life-Plan for elderly patients should be established. A multidisciplinary approach led by nephrologists can help them to provide proper vascular access for dialysis at the right time, with the right evidence, and to the right patient. Strategies that can improve peritoneal dialysis in elderly patients include assisted peritoneal dialysis, homecare support programs, and automated peritoneal dialysis. In order to enhance the role of kidney transplantation in elderly patients with ESKD, it is necessary to accurately identify patients' clinical conditions before transplantation and to perform active rehabilitation activities and postoperative management to promote recovery after transplantation. With the aging population and the increase in ESKD in the elderly, clinicians must identify factors affecting the mortality and quality of life of elderly dialysis patients.

Keywords: Elderly; End-Stage Kidney Disease Life-Plan; Hemodialysis; Kidney transplantation; Peritoneal dialysis; Renal replacement therapy; Shared decision making.

Fig. 1. The prevalence of ESKD among people aged 65 years or older in South Korea was 54.6% in 2020 and has steadily increased since the 1990s. X-axis, age; Y-axis, year (adopted from KORDS, 2020). Abbreviations: KORDS, Korean Renal Data System.

Fig. 2. ESKD Life-Plan and Associated Access Needs: What’s the PLAN? (modified from the Figure 1.1 of 2019 K/DOQI guidelines Abbreviations: HD, hemodialysis: PD, peritoneal dialysis, KRT, kidney replacement therapy.

Fig. 3. Mortality rate for dialysis patients in Korea. In 2018, the unadjusted mortality rate for dialysis patients was 45.18 per 1,000 patient-years, and mortality rates by dialysis modality were 45.10 for HD patients and 51.33 for PD patients per 1,000 patient-years. (adopted from KORDS, 2020) Abbreviations: HD, hemodialysis: PD, peritoneal dialysis, KORDS, Korean Renal Data System.