In the United States, as in many other developed countries, the incidence of treated end stage renal disease (ESRD) increases with advancing age; the highest rates are observed in individuals between the ages of 75 and 79 (Figure 1) (1). There is concern, however, that the functional rehabilitation of elderly dialysis patients is often unsatisfactory and the gain in life expectancy with renal replacement therapy is rather modest. This should not be surprising, because elderly patients with ESRD have a significantly greater burden of coexisting illnesses and are more likely to be frail.
Unique psychosocial issues that interplay with medical conditions must be factored in when planning for renal replacement therapy for the elderly. Consequently, nephrologists grapple with several important issues when dealing with an elderly patient with advanced chronic kidney disease (CKD): Is dialysis planning appropriate for all elderly CKD patients? Does dialysis therapy improve the functional status and increase the life expectancy of the frail elderly, and is there a role for maximum conservative therapy? Does dialysis increase the risk of death in elderly patients if started at a higher level of estimated glomerular filtration rate (eGFR)? Is one dialysis modality better than the other for elderly patients with ESRD?
US Renal Data System. UADRAoCKDaE-SRDitUS, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2010.
Keith DS, et al.. Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Intern Med 2004; 164:659–663.
US Renal Data System. UADRAoCKDaE-SRDitUS, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2009.
Kurella Tamura M, et al.. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009; 361:1539–1547.
Carson RC, et al.. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 2009; 4:1611–1619.
Rosansky SJ, et al.. Initiation of dialysis at higher GFRs: is the apparent rising tide of early dialysis harmful or helpful? Kidney Int 2009; 76:257–261.
Kazmi WH, et al.. Effect of comorbidity on the increased mortality associated with early initiation of dialysis. Am J Kidney Dis 2005; 46:887–896.
Cooper BA, et al.. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med 2010; 363:609–619.
Jiwakanon S, et al.. Peritoneal dialysis: an underutilized modality. Curr Opin Nephrol Hypertens 2010; 19:573–577.
Mehrotra R, et al.. Chronic peritoneal dialysis in the United States: declining utilization despite improving outcomes. J Am Soc Nephrol 2007; 18:2781–2788.
Mehrotra R, et al.. Similar outcomes with hemodialysis and peritoneal dialysis in patients with end-stage renal disease. Arch Intern Med 2010.