Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Epidemiology and management of end-stage renal disease in the elderly

Nature Reviews Nephrology volume 7, pages 591–598 (2011)Cite this article

Subjects

Abstract

Elderly patients with end-stage renal disease (ESRD) are at increased risk of developing aging-related problems, such as frailty, impaired physical function, falls, poor nutrition and cognitive impairment. These factors affect dialysis outcomes, which can be very poor in frail, elderly patients who often experience a decline in overall health and physical function and have short survival. The default treatment option for these patients is hospital-based hemodialysis, often with little consideration of how this modality will affect the survival or quality of life of individual patients. A comparison of quality of life of elderly patients on hemodialysis versus peritoneal dialysis shows that those on peritoneal dialysis have less illness intrusion. Assisted peritoneal dialysis enables a greater number of frail, elderly patients to have dialysis in their own homes. Dialysis may not extend survival for those with multiple comorbidities, so conservative care (nondialysis treatment) should be considered. To improve the outcomes of elderly patients with ESRD, it is necessary to develop a realistic approach to overall prognosis, quality of life and how the patient copes with the disabilities associated with aging. This approach includes having discussions regarding choice of treatment and end-of-life goals with patients and families.

Key Points

  • Elderly patients with end-stage renal disease have more disabilities associated with old age than do the general population

  • Starting on hemodialysis is associated with a decline in the physical function of frail, elderly patients

  • Elderly patients on peritoneal dialysis have less illness intrusion than elderly patients on hemodialysis

  • Assisted peritoneal dialysis enables a greater number of elderly patients to have their dialysis treatment at home

  • Transplantation can be successful in elderly patients and age is not a contraindication

  • Delaying dialysis and discussing the option of conservative care will improve the quality of the end-of-life phase for elderly patients with multiple comorbidities

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

References

  1. Rowe, J. W. & Kahn, R. L. Successful aging. Gerontologist 37, 433–440 (1997).

    Article  CAS  PubMed  Google Scholar 

  2. Phelan, E. A., Anderson, L. A., LaCroix, A. Z. & Larson, E. B. Older adults' views of “successful aging”—how do they compare with researchers' definitions? J. Am. Geriatr. Soc. 52, 211–216 (2004).

    Article  PubMed  Google Scholar 

  3. Campbell, A. J. & Buchner, D. M. Unstable disability and the fluctuations of frailty. Age Ageing 26, 315–318 (1997).

    Article  CAS  PubMed  Google Scholar 

  4. Fried, L. P. et al. for the Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J. Gerontol. A Biol. Sci. Med. Sci. 56, M146–M156 (2001).

    Article  CAS  PubMed  Google Scholar 

  5. Johansen, K. L., Chertow, G. M., Jin, C. & Kutner, N. G. Significance of frailty among dialysis patients. J. Am. Soc. Nephrol. 18, 2960–2967 (2007).

    Article  PubMed  Google Scholar 

  6. Ansell, D. et al. The Ninth Annual Report. UK Renal Registry [online], (2006).

    Google Scholar 

  7. Ansell, D. et al. The Twelfth Annual Report. UK Renal Registry [online], (2009).

    Google Scholar 

  8. US Renal Data System. USRDS 2010 Annual Data Report: Atlas of End-Stage Renal Disease in the United States [online], (2010).

  9. Challah, S., Wing, A. J., Bauer, R., Morris, R. W. & Schroeder, S. A. Negative selection of patients for dialysis and transplantation in the United Kingdom. Br. Med. J. (Clin. Res. Ed.) 288, 1119–1122 (1984).

    Article  CAS  Google Scholar 

  10. Joly, D. et al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. J. Am. Soc. Nephrol. 14, 1012–1021 (2003).

    Article  PubMed  Google Scholar 

  11. Roderick, P. et al. Late referral for end-stage renal disease: a region-wide survey in the south west of England. Nephrol. Dial. Transplant. 17, 1252–1259 (2002).

    Article  PubMed  Google Scholar 

  12. Kurella, M. et al. Chronic kidney disease and cognitive impairment in the elderly: the Health, Aging, and Body Composition study. J. Am. Soc. Nephrol. 16, 2127–2133 (2005).

    Article  PubMed  Google Scholar 

  13. Chiu, E., Markowitz, S. N., Cook, W. L. & Jassal, S. V. Visual impairment in elderly patients receiving long-term hemodialysis. Am. J. Kidney Dis. 52, 1131–1138 (2008).

    Article  PubMed  Google Scholar 

  14. Ifudu, O. et al. Dismal rehabilitation in geriatric inner-city hemodialysis patients. JAMA 271, 29–33 (1994).

    Article  CAS  PubMed  Google Scholar 

  15. Cook, W. L. & Jassal, S. V. Functional dependencies among the elderly on hemodialysis. Kidney Int. 73, 1289–1295 (2008).

    Article  CAS  PubMed  Google Scholar 

  16. Jassal, S. V., Chiu, E. & Hladunewich, M. Loss of independence in patients starting dialysis at 80 years of age or older. N. Engl. J. Med. 361, 1612–1613 (2009).

    Article  CAS  PubMed  Google Scholar 

  17. Kurella Tamura, M. et al. Functional status of elderly adults before and after initiation of dialysis. N. Engl. J. Med. 361, 1539–1547 (2009).

    Article  PubMed  Google Scholar 

  18. Kurella Tamura, M. & Yaffe, K. Dementia and cognitive impairment in ESRD: diagnostic and therapeutic strategies. Kidney Int. 79, 14–22 (2011).

    Article  PubMed  Google Scholar 

  19. Murray, A. M. et al. Cognitive impairment in hemodialysis patients is common. Neurology 67, 216–223 (2006).

    Article  CAS  PubMed  Google Scholar 

  20. Plassman, B. L. et al. Prevalence of cognitive impairment without dementia in the United States. Ann. Intern. Med. 148, 427–434 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  21. Weiner, D. E. The cognition-kidney disease connection: lessons from population-based studies in the United States. Am. J. Kidney Dis. 52, 201–204 (2008).

    Article  PubMed  Google Scholar 

  22. Madero, M., Gul, A. & Sarnak, M. J. Cognitive function in chronic kidney disease. Semin. Dial. 21, 29–37 (2008).

    Article  PubMed  Google Scholar 

  23. Pereira, A. A., Weiner, D. E., Scott, T. & Sarnak, M. J. Cognitive function in dialysis patients. Am. J. Kidney Dis. 45, 448–462 (2005).

    Article  PubMed  Google Scholar 

  24. Kurella, M., Mapes, D. L., Port, F. K. & Chertow, G. M. Correlates and outcomes of dementia among dialysis patients: the Dialysis Outcomes and Practice Patterns Study. Nephrol. Dial. Transplant. 21, 2543–2548 (2006).

    Article  PubMed  Google Scholar 

  25. Cohen, L. M., Ruthazer, R., Moss, A. H. & Germain, M. J. Predicting six-month mortality for patients who are on maintenance hemodialysis. Clin. J. Am. Soc. Nephrol. 5, 72–79 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  26. Petersen, R. C. et al. Current concepts in mild cognitive impairment. Arch. Neurol. 58, 1985–1992 (2001).

    Article  CAS  PubMed  Google Scholar 

  27. Sánchez-Perales, C. et al. Ischaemic stroke in incident dialysis patients. Nephrol. Dial. Transplant. 25, 3343–3348 (2010).

    Article  CAS  PubMed  Google Scholar 

  28. Cook, W. L. et al. Falls and fall-related injuries in older dialysis patients. Clin. J. Am. Soc. Nephrol. 1, 1197–1204 (2006).

    Article  PubMed  Google Scholar 

  29. Tinetti, M. E., Speechley, M. & Ginter, S. F. Risk factors for falls among elderly persons living in the community. N. Engl. J. Med. 319, 1701–1707 (1988).

    Article  CAS  PubMed  Google Scholar 

  30. Power, A. et al. High but stable incidence of subdural haematoma in haemodialysis—a single-centre study. Nephrol. Dial. Transplant. 25, 2272–2275 (2010).

    Article  PubMed  Google Scholar 

  31. Graham, J. E. et al. Prevalence and severity of cognitive impairment with and without dementia in an elderly population. Lancet 349, 1793–1796 (1997).

    Article  CAS  PubMed  Google Scholar 

  32. Watnick, S., Kirwin, P., Mahnensmith, R. & Concato, J. The prevalence and treatment of depression among patients starting dialysis. Am. J. Kidney Dis. 41, 105–110 (2003).

    Article  PubMed  Google Scholar 

  33. Charney, D. S. et al. for the Depression and Bipolar Support Alliance. Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Arch. Gen. Psychiatry 60, 664–672 (2003).

    Article  PubMed  Google Scholar 

  34. Goodpaster, B. H. et al. The loss of skeletal muscle strength, mass, and quality in older adults: the Health, Aging and Body Composition study. J. Gerontol. A Biol. Sci. Med. Sci. 61, 1059–1064 (2006).

    Article  PubMed  Google Scholar 

  35. Hughes, V. A., Frontera, W. R., Roubenoff, R., Evans, W. J. & Singh, M. A. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am. J. Clin. Nutr. 76, 473–481 (2002).

    Article  CAS  PubMed  Google Scholar 

  36. Cornoni-Huntley, J. C. et al. An overview of body weight of older persons, including the impact on mortality. The National Health and Nutrition Examination Survey I—Epidemiologic Follow-Up Study. J. Clin. Epidemiol. 44, 743–753 (1991).

    Article  CAS  PubMed  Google Scholar 

  37. Newman, A. B. et al. for the Cardiovascular Study Research Group. Weight change in old age and its association with mortality. J. Am. Geriatr. Soc. 49, 1309–1318 (2001).

    Article  CAS  PubMed  Google Scholar 

  38. Garibotto, G. et al. Skeletal muscle protein synthesis and degradation in patients with chronic renal failure. Kidney Int. 45, 1432–1439 (1994).

    Article  CAS  PubMed  Google Scholar 

  39. Carrero, J. J. et al. Comparison of nutritional and inflammatory markers in dialysis patients with reduced appetite. Am. J. Clin. Nutr. 85, 695–701 (2007).

    Article  CAS  PubMed  Google Scholar 

  40. Ikizler, T. A. Protein and energy: recommended intake and nutrient supplementation in chronic dialysis patients. Semin. Dial. 17, 471–478 (2004).

    Article  PubMed  Google Scholar 

  41. Aparicio, M. et al. Nutritional status of haemodialysis patients: a French national cooperative study. French Study Group for Nutrition in Dialysis. Nephrol. Dial. Transplant. 14, 1679–1686 (1999).

    Article  CAS  PubMed  Google Scholar 

  42. Cianciaruso, B. et al. Nutritional status in the elderly patient with uraemia. Nephrol. Dial. Transplant. 10 (Suppl. 6), 65–68 (1995).

    Article  PubMed  Google Scholar 

  43. Marcén, R., Teruel, J. L., de la Cal, M. A. & Gámez, C. The impact of malnutrition in morbidity and mortality in stable haemodialysis patients. Spanish Cooperative Study of Nutrition in Hemodialysis. Nephrol. Dial. Transplant. 12, 2324–2331 (1997).

    Article  PubMed  Google Scholar 

  44. Qureshi, A. R. et al. Factors predicting malnutrition in hemodialysis patients: a cross-sectional study. Kidney Int. 53, 773–782 (1998).

    Article  CAS  PubMed  Google Scholar 

  45. Stenvinkel, P. et al. Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney Int. 55, 1899–1911 (1999).

    Article  CAS  PubMed  Google Scholar 

  46. Burrowes, J. D. et al. Cross-sectional relationship between dietary protein and energy intake, nutritional status, functional status, and comorbidity in older versus younger hemodialysis patients. J. Ren. Nutr. 12, 87–95 (2002).

    Article  PubMed  Google Scholar 

  47. Burrowes, J. D. et al. for the Hemodialysis (HEMO) Study Group. Effects of dietary intake, appetite, and eating habits on dialysis and non-dialysis treatment days in hemodialysis patients: cross-sectional results from the HEMO study. J. Ren. Nutr. 13, 191–198 (2003).

    Article  PubMed  Google Scholar 

  48. Locher, J. L., Robinson, C. O., Roth, D. L., Ritchie, C. S. & Burgio, K. L. The effect of the presence of others on caloric intake in homebound older adults. J. Gerontol. A Biol. Sci. Med. Sci. 60, 1475–1478 (2005).

    Article  PubMed  Google Scholar 

  49. Stratton, R. J. et al. Multinutrient oral supplements and tube feeding in maintenance dialysis: a systematic review and meta-analysis. Am. J. Kidney Dis. 46, 387–405 (2005).

    Article  CAS  PubMed  Google Scholar 

  50. Schaeffner, E. S., Rose, C. & Gill, J. S. Access to kidney transplantation among the elderly in the United States: a glass half full, not half empty. Clin. J. Am. Soc. Nephrol. 5, 2109–2114 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  51. Knoll, G. A. Is kidney transplantation for everyone? The example of the older dialysis patient. Clin. J. Am. Soc. Nephrol. 4, 2040–2044 (2009).

    Article  PubMed  Google Scholar 

  52. Rao, P. S. et al. Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipients. Transplantation 83, 1069–1074 (2007).

    Article  PubMed  Google Scholar 

  53. Heldal, K. et al. Benefit of kidney transplantation beyond 70 years of age. Nephrol. Dial. Transplant. 25, 1680–1687 (2010).

    Article  PubMed  Google Scholar 

  54. Stevens, K. K. et al. Deceased donor transplantation in the elderly—are we creating false hope? Nephrol. Dial. Transplant. 26, 2382–2386 (2011).

    Article  PubMed  Google Scholar 

  55. Cohen, B. et al. Expanding the donor pool to increase renal transplantation. Nephrol. Dial. Transplant. 20, 34–41 (2005).

    Article  PubMed  Google Scholar 

  56. Lindsay, R. M., Heidenheim, P. A., Nesrallah, G., Garg, A. X. & Suri, R. for the Daily Hemodialysis Study Group London Health Sciences Centre. Minutes to recovery after a hemodialysis session: a simple health-related quality of life question that is reliable, valid, and sensitive to change. Clin. J. Am. Soc. Nephrol. 1, 952–959 (2006).

    Article  PubMed  Google Scholar 

  57. Pisoni, R. L. et al. Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis. Am. J. Kidney Dis. 53, 475–491 (2009).

    Article  PubMed  Google Scholar 

  58. Lazarides, M. K., Georgiadis, G. S., Antoniou, G. A. & Staramos, D. N. A meta-analysis of dialysis access outcome in elderly patients. J. Vasc. Surg. 45, 420–426 (2007).

    Article  PubMed  Google Scholar 

  59. ERA-EDTA. European Renal Association and European Dialysis and Transplant Association annual report 2007 [online], (2009).

  60. Oliver, M. J. et al. Home care assistance and the utilization of peritoneal dialysis. Kidney Int. 71, 673–678 (2007).

    Article  CAS  PubMed  Google Scholar 

  61. Verger, C. et al. French Peritoneal Dialysis Registry (RDPLF): outline and main results. Kidney Int. Suppl. 103, S12–S20 (2006).

    Article  Google Scholar 

  62. Li, P. K. & Szeto, C. C. Success of the peritoneal dialysis programme in Hong Kong. Nephrol. Dial. Transplant. 23, 1475–1478 (2008).

    Article  PubMed  Google Scholar 

  63. Couchoud, C. et al. Associations between comorbidities, treatment choice and outcome in the elderly with end-stage renal disease. Nephrol. Dial. Transplant. 22, 3246–3254 (2007).

    Article  PubMed  Google Scholar 

  64. Brown, E. A., Dratwa, M. & Povlsen, J. V. Assisted peritoneal dialysis—an evolving dialysis modality. Nephrol. Dial. Transplant. 22, 3091–3092 (2007).

    Article  PubMed  Google Scholar 

  65. Kurella, M., Covinsky, K. E., Collins, A. J. & Chertow, G. M. Octogenarians and nonagenarians starting dialysis in the United States. Ann. Intern. Med. 146, 177–183 (2007).

    Article  PubMed  Google Scholar 

  66. Castrale, C. et al. Peritoneal dialysis in elderly patients: report from the French Peritoneal Dialysis Registry (RDPLF). Nephrol. Dial. Transplant. 25, 255–262 (2010).

    Article  PubMed  Google Scholar 

  67. Jassal, S. V., Trpeski, L., Zhu, N., Fenton, S. & Hemmelgarn, B. Changes in survival among elderly patients initiating dialysis from 1990 to 1999. CMAJ 177, 1033–1038 (2007).

    Article  PubMed  PubMed Central  Google Scholar 

  68. Lamping, D. L. et al. Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study. Lancet 356, 1543–1550 (2000).

    Article  CAS  PubMed  Google Scholar 

  69. Harris, S. A., Lamping, D. L., Brown, E. A. & Constantinovici, N. for the North Thames Dialysis Study (NTDS) Group. Clinical outcomes and quality of life in elderly patients on peritoneal dialysis versus hemodialysis. Perit. Dial. Int. 22, 463–470 (2002).

    PubMed  Google Scholar 

  70. Brown, E. A. et al. Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients. Nephrol. Dial. Transplant. 25, 3755–3763 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  71. Rosansky, S. J., Clark, W. F., Eggers, P. & Glassock, R. J. Initiation of dialysis at higher GFRs: is the apparent rising tide of early dialysis harmful or helpful? Kidney Int. 76, 257–261 (2009).

    Article  PubMed  Google Scholar 

  72. Cooper, B. A. et al. A randomized, controlled trial of early versus late initiation of dialysis. N. Engl. J. Med. 363, 609–619 (2010).

    Article  CAS  PubMed  Google Scholar 

  73. Lassalle, M. et al. Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival. Kidney Int. 77, 700–707 (2010).

    Article  PubMed  Google Scholar 

  74. Ahmed, A. K., Kamath, N. S., El Kossi, M. & El Nahas, A. M. The impact of stopping inhibitors of the renin-angiotensin system in patients with advanced chronic kidney disease. Nephrol. Dial. Transplant. 25, 3977–3982 (2010).

    Article  CAS  PubMed  Google Scholar 

  75. Knauf, F. & Aronson, P. S. ESRD as a window into America's cost crisis in health care. J. Am. Soc. Nephrol. 20, 2093–2097 (2009).

    Article  PubMed  Google Scholar 

  76. Murtagh, F. E. et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol. Dial. Transplant. 22, 1955–1962 (2007).

    Article  PubMed  Google Scholar 

  77. Chandna, S. M. et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol. Dial. Transplant. 26, 1608–1614 (2011).

    Article  PubMed  Google Scholar 

  78. Brunori, G. et al. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. Am. J. Kidney Dis. 49, 569–580 (2007).

    Article  CAS  PubMed  Google Scholar 

  79. Murtagh, F. E., Addington-Hall, J. M. & Higginson, I. J. End-stage renal disease: a new trajectory of functional decline in the last year of life. J. Am. Geriatr. Soc. 59, 304–308 (2011).

    Article  PubMed  Google Scholar 

  80. Carson, R. C., Juszczak, M., Davenport, A. & Burns, A. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin. J. Am. Soc. Nephrol. 4, 1611–1619 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  81. De Vecchi, A. F., Dratwa, M. & Wiedemann, M. E. Healthcare systems and end-stage (ESRD) therapies—an international review: costs and reimbursement/funding of ESRD therapies. Nephrol. Dial. Transplant. 14 (Suppl. 6), 31–41 (1999).

    Article  PubMed  Google Scholar 

  82. Mendelssohn, D. C. et al. A prospective evaluation of renal replacement therapy modality eligibility. Nephrol. Dial. Transplant. 24, 555–561 (2009).

    Article  PubMed  Google Scholar 

  83. O'Hare, A. M., Rodriguez, R. A., Hailpern, S. M., Larson, E. B. & Kurella Tamura, M. Regional variation in health care intensity and treatment practices for end-stage renal disease in older adults. JAMA 304, 180–186 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  84. Schell, J. O., Germain, M. J., Finkelstein, F. O., Tulsky, J. A. & Cohen, L. M. An integrative approach to advanced kidney disease in the elderly. Adv. Chronic Kidney Dis. 17, 368–377 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Renal Department, Imperial College Kidney and Transplant Centre, Hammersmith Hospital, Du Cane Road, W12 0HS, London, UK

    Edwina A. Brown & Lina Johansson

Authors
  1. Edwina A. Brown
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lina Johansson
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

E. A. Brown wrote the article. Both authors researched data for the article, made a substantial contribution to discussion of content and reviewed and edited the manuscript before submission.

Corresponding author

Correspondence to Edwina A. Brown.

Ethics declarations

Competing interests

E. A. Brown has received speakers bureau honoraria from Baxter Healthcare. L. Johansson declares no competing interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Brown, E., Johansson, L. Epidemiology and management of end-stage renal disease in the elderly. Nat Rev Nephrol 7, 591–598 (2011). https://doi.org/10.1038/nrneph.2011.113

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrneph.2011.113

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing