The number of elderly patients who need renal replacement therapy (RRT) for ESRD grows steadily coincident with the overall aging of the population and with the increasing frequency with which elderly patients are accepted for such treatment. The most rapid growth among all new ESRD patients is in those who are 65–74 years of age. Individual countries show a marked variation in their trends in the use of RRT, possibly reflecting the variability in the accessibility to health care worldwide.
Elderly patients are less likely than younger patients to have ESRD secondary to GN (except in Japan where the number of elderly patients with GN is increasing) but are more likely to have renal failure due to type 2 diabetes and/or hypertension and to renal vascular disease. Such patients have many comorbid conditions that make therapy considerably more difficult and require multidisciplinary work and special knowledge of geriatric medicine.
Experience with elderly patients with renal diseases and uremia is still limited. For ethical reasons, there are very few comparative studies and no randomized, prospective studies have been conducted. In addition, these studies are based on populations that differ considerably in both medical and social characteristics.
Predialysis Management and Initiation of Dialysis
In elderly patients, chronic renal failure is characterized by an absence of classic symptoms, the nonspecific nature of the presenting symptoms, the presence of comorbid conditions, and by interference with the interpretation of findings by the aging process. Therefore these patients require regular screening for comorbid conditions, screening for cancer [prostate-specific antigen (PSA), Pap smear, mammography, renal ultrasound or CT, X-ray], review of medications with an emphasis on over-the-counter drugs, the possibility of drug interactions, dosing, adequate vaccination, examination of feet, especially in diabetics, and, if necessary, psychiatric and social intervention.
The elderly show a poor correlation between serum creatinine and glomerular filtration rate and therefore it is preferable to monitor creatinine clearance measured or calculated from serum creatinine. Salt intake should be limited to 4–5 g/L/day and regular clinical monitoring of fluid overload and/or dehydration is advisable. Severe constipation, which is frequent in the elderly, may exacerbate hyperkalemia. In the predialysis phase [chronic kidney disease (CKD) stages 3–4], the use of recombinant human erythropoietin (rh-EPO) may improve the quality of life (QOL) and prevent left ventricular hypertrophy. Strict dietary protein restriction is often unnecessary (acceptable ingestion: 60–70 g protein/day). Also, to avoid acidosis, special attention should be paid to serum bicarbonate levels.
Late referral to a nephrology unit is significantly related to early death. On some occasions, it is not that the elderly are not referred early, but that the nephrologist may have delayed initiation of dialysis due to misleading serum creatinine levels. Therefore, the National Kidney Foundation Disease Outcomes Quality Initiative (NKF-DOQI) guidelines suggest that regular estimations of weekly creatinine clearance to avoid late initiation of dialysis should be performed. An early referral may provide better salt and water balance and better control of anemia, leading to a decrease in overall morbidity and mortality. Initiation of dialysis should be recommended before uremic symptoms become overt and particularly before there is evidence of malnutrition. A low serum albumin level, a dietary protein intake <0.7 g/kg/day, weight loss, and a decrease in muscle mass indicate the need for dialysis.
In most countries hospital hemodialysis, which is the principal form of RRT in the elderly, offers many advantages. Dialysis is performed by nurses, the treatment time is shorter, it allows for socialization with staff and other patients, and there is continuous follow-up by the medical team.
Crucial to successful hemodialysis is the presence of a functional vascular access. Proper planning for such an access requires comprehensive evaluation with respect to earlier placement of vascular catheters, the presence of a cardiac pacemaker on a prosthetic cardiac valve, the presence of enlarged axillary lymph nodes, and past radiation therapy. Diabetes and hypertension, the most frequent causes of ESRD in the elderly, are associated with abnormal blood vessels. A good forearm Brescia–Cimino arteriovenous fistula is the ideal form of vascular access whatever the patient's age. However, there is a higher primary failure rate and shorter survival with this form of access in the elderly. Among the various vascular substitutes, the homologous saphenous vein graft proved to be superior to other synthetic grafts. In some elderly patients, particularly those with diabetes, synthetic grafts can be very useful. Vascular-access thrombosis associated with rh-EPO therapy was more common in elderly patients for both native arteriovenous fistulas and grafts. In cases of late referral, “trial dialysis,” and a failed arteriovenous fistula, both cuffed and noncuffed catheters may provide suitable vascular access.
Hemodialysis is more likely to precipitate cardiovascular instability in the elderly. Some investigators reported more frequent episodes of hypotension during dialysis and/or postdialysis, which may be a risk factor for falls. In elderly patients who have autonomic dysfunction and a low cardiac reserve, hypotension during hemodialysis may be a consequence of rapid ultrafiltration. Also, the incidence of arrhythmias increases progressively with age and in such patients arrhythmias could be a risk factor for cardiac death. While on hemodialysis, elderly patients may develop gastrointestinal bleeding due to gastritis, duodenal ulceration, and angiodysplasia.
Although it is rarely used, home dialysis is a highly successful therapeutic option. Individuals on home hemodialysis have few dialysis-related complications.
Chronic Peritoneal Dialysis
Chronic peritoneal dialysis (CPD) offers many advantages including good control of hypertension, independence from hospitals, simplicity of access, better cardiovascular stability (less hypotension and fewer arrhythmias), and slow solute removal. A family member may perform such dialysis and the patient does not need to go to the hospital three times a week. On the other hand, patients are at higher risk of complications such as malnutrition, which is more frequent in the elderly than in younger peritoneal dialysis (PD) patients and which is highly correlated with mortality. In addition, low initial albumin levels correlate with mortality among elderly patients on continuous ambulatory peritoneal dialysis (CAPD) and cachexia is a frequent cause of death.
Elderly patients with uremia have an increased risk of infection because they suffer from immunodeficiency, malnutrition, and high rates of bowel disease, which may explain the higher rates of peritonitis among the elderly on PD. Bedridden patients tend to have an even higher rate of peritonitis. Catheter-related complications are infrequent among elderly patients on PD, probably because they are less active than younger patients. The higher incidence of hernias (incisional, inguinal) in elderly PD patients has been attributed to weakness of the abdominal wall.
Hospitalization rates are higher among elderly than among younger patients, especially among those of African descent and diabetics. The duration of stay varies between 5.5 and 23.1 in-hospital days.
PD is not used extensively among the elderly because they are unable to perform dialysis by themselves; about 61.2% of very old patients (above 80 years) need help with dialysis exchanges, exit-site care, and medication. Many patients older than 65 years suffer from comorbid conditions such as depression, dementia, impaired vision, and decreased physical and mental activity, all of which significantly impair self-performance of PD. However, given a network of medical, nursing, and social support, the elderly can perform PD (especially automated PD) successfully at home.
Renal transplantation may be successful in the elderly; perioperative survival is comparable to that among younger recipients. However, in Europe, only 2% of patients older than 65 years and less than 0.3% of patients older than 75 years receive renal transplants, except in Norway, where transplantation is the primary mode of therapy for patients 60–65 years old. Lower transplantation rates among the elderly may be explained not only by selection bias but also by a shortage of organ donation; older patients tend to have fewer living donors and younger persons are less willing to donate a kidney to an older relative than to a younger one. The shortage of kidneys could be improved in older recipients by using kidneys from older cadaveric donors. Kidneys from elderly donors may be suitable for elderly recipients who have lower muscle mass and less metabolic demands coupled with decreased immunologic reactivity, thus allowing the use of less aggressive immunosuppressive regimens without increasing rejection rates. However, special attention should be paid to age and size matching between donor and recipient and to cold ischemia time, which should be as short as possible. No differences in kidney survival were found in a comparison of elderly patients previously treated by hemodialysis or CAPD. Over the past 10 years the improvement in overall patient and graft survival rates may be related to increased experience with the use of newer immunosuppressive regimes [United States Renal Data System (USRDS), Canadian Organ Replacement Register (CORR)] in the elderly.
With the growing number of elderly patients requiring dialysis, an increasing number need assisted care.
Trained home-care nurses may provide the elderly with comfortable and safe home dialysis without reliance on family members. Also, the low rate of infection and hospitalization and the avoidance of transportation in this high-risk population achieve significant savings. The rates of peritonitis and exit-site infection are not significantly different between those who had assisted dialysis by a home-care nurse and those on self-dialysis. The home-care nurse may assist in the treatment of episodes of peritonitis and other complications, thereby contributing to a lower total hospitalization rate.
Rehabilitation and Chronic Care Dialysis Units
Rehabilitation and chronic care dialysis units (RCDUs) may provide dialysis, physiotherapy, a rehabilitation program, and occupational therapy for those patients who cannot return home or who cannot be placed in a nursing home. Such units achieve significant reduction in costs compared to hospital treatment and this cost reduction is not accompanied by any deterioration in the elderly person's QOL.
Dialysis in the Nursing Home
An increasing number of the elderly will live in a nursing home in the future. A substantial number of nursing homes still refuse to introduce dialysis into everyday care because they believe that the ESRD elderly population is difficult to care for, because they lack knowledge about dialysis and renal diet and lack adequate storage space for machines and supplies, and because there is poor communication with the renal team.
Although hemodialysis is the mode most used in nursing homes, published data are limited and, until now, there have been no control trials. Nursing home residents on hemodialysis spend about 15 hours in the dialysis unit per week; this coupled with transportation time takes time away from rehabilitation and social activities. The need for transportation may be overcome by building the dialysis center within or adjacent to a skilled nursing facility.
PD in nursing homes offers many advantages and allows flexibility in schedules for patients and for staff. In this regard, automated PD (APD) or nightly PD frees the patients' daytime for nursing home activities, increases socialization, and results in better rehabilitation, which improves their QOL. Patients on PD in nursing homes and day care centers have a lower survival rate than the general CAPD population. This is probably a reflection of patient selection because patients in nursing homes are significantly older and have many comorbid conditions. It seems that rates of peritonitis do not differ significantly from those in the overall noninstitutionalized elderly.
Dialysis in the elderly is a life-extending treatment, and, for many, these are lives of quality. However, some older individuals elect to cease dialysis because of QOL issues. For this reason, health care professionals should be completely honest when educating patients and their families regarding the burdens associated with living on dialysis. They cannot make this decision for others but should share their knowledge and experience and advise patients without projecting their own prejudices. With respect to the decision-making process, the first published guidelines that appeared in 1993 were personal and did not reflect the opinion of the majority. A set of consensus guidelines, published by the NKF in 1996, allowed all patients to explore their own options. Finally, the American Society of Nephrology and the Renal Physicians Association published evidence-based guidelines in 2000. All of these publications emphasize that they are just guidelines and not rules; they also emphasize the difficulties of the decision-making process arising from the heterogeneous nature of both providers and the patient population. None of the guidelines recommend mandatory standards for the determination of the patient's candidacy for dialysis.
Sometimes neither the medical team nor the patient or family members find it easy to reach a decision. In that case, the patient should be offered a period of trial dialysis, say for of 30–90 days. All guidelines recommend that dialysis not be offered to patients with a known serious terminal illness or patients who have serious mental impairment as a result of stroke, Alzheimer's disease, or neurologic dysfunction. Also, patients on dialysis who develop a terminal illness or become demented should be offered the option of discontinuing dialysis. Patients choosing to withdraw from dialysis should know that they will receive ongoing active, caring treatment to minimize suffering and prevent pain.
Withdrawal from dialysis is more frequent among elderly patients, particularly among those living in a nursing home. However, this high discontinuation rate among elderly patients is not due to dialysis per se but rather to associated social and medical circumstances.
Cassidy MJD, Sims RJA: Dialysis in the elderly. New possibilities, new problems. Minerva Urolog Nephrol 2004;56:305.
Fehrman-Ekhom I, Skeppholm L: Renal function in the elderly (>70 years old) measured by means of iohexol
clearance, serum creatinine, serum urea and estimated clearance. Scand J Urol Nephrol 2004;38:73.
Vistoli F et al: Kidney transplantation from donors aged more than 65 years. Transplant Proc 2004;36:481.
Yamagata K et al: Age distribution and yearly changes in the incidence of ESRD in Japan. Am J Kidney Dis 2004;43(3):433.