Compared to younger individuals, the prevalence of end-stage renal disease (ESRD) in elders is notably higher. While renal replacement therapy, usually with hemodialysis, is accepted therapy in younger patients with ESRD, decisions regarding the treatment of advanced kidney disease in the elderly population are more complex, secondary to the physiologic changes of aging, concurrent geriatric syndromes, and varying goals of care.
The results of studies comparing mortality between hemodialysis and peritoneal dialysis in older adults have been mixed. Data regarding short-term mortality is limited in the United States due to a lack of Medicare reporting as they do not become the principal payer until 90 days after dialysis initiation. Studies have found increased mortality among diabetic patients receiving peritoneal dialysis compared to hemodialysis.
A meta-analysis done in Korean patients by Han et al. showed a higher death rate in elderly PD patients than those on HD. There was no difference in the quality of life and physical function between PD and HD patients in the age group of 60 plus. Kidney transplantation, while performed less frequently than dialysis in the geriatric population, has been shown to increase life expectancy and improve quality of life compared to dialysis.
In a study by Wolfe et al. comparing mortality in wait-listed dialysis patients versus recipients of a first cadaveric transplant, the transplant recipients demonstrated improved longevity at all ages, including patients who were 60 to 74 years of age. Another study showed a 41% overall adjusted relative risk of death for transplant patients in comparison to wait-listed dialysis patients.
Determining who would derive the greatest benefit from transplants given the shortage of donor organs will continue to be an important ethical consideration as increasing numbers of individuals survive into advanced old age with ESRD. The number of older adults is rapidly increasing across the world. It is projected that 98 million adults will be 65 years of age or older by 2060.
With aging, there is an increase in overall health care expenditure and, in general, chronic kidney disease is one of the most fiscally burdensome conditions. In 2013, the cost for chronic kidney disease care among Medicare beneficiaries 65 years of age and older exceeded 50 billion. Dialysis increases life span, provides symptom relief from fluid overload and toxins, improves quality of life, and can help fulfill personal wishes.
Dialysis also comes with side effects and complications, especially in patients with multiple co-morbidities. Age by itself is not a contra-indication for dialysis. However, when coupled with multiple co-morbidities, geriatric syndromes, and functional impairment, it may not be the best treatment decision for all patients. In fact, among this population, dialysis can result in a reduction in quality of life. Therefore, the decision-making process regarding dialysis in the geriatric population should be multi-disciplinary in nature and focus on individual patient/family goals.