Dialysis is a life-sustaining treatment for end-stage renal disease (ESRD), a condition where the kidneys permanently fail and can no longer filter waste and fluid from the blood. The two primary forms are hemodialysis (HD), which uses an external machine, and peritoneal dialysis (PD), which uses the patient’s abdominal lining as a filter. While dialysis offers a necessary bridge for survival, its application in the elderly population is complex. The treatment’s ability to prolong life is often weighed against an amplified risk of complications and a potential reduction in quality of life for older adults.
Age-Related Factors Increasing Dialysis Risk
The increased vulnerability of older adults to dialysis risks begins with a diminished physiological reserve, which is the body’s reduced capacity to cope with physical stress. This reduced reserve means that the elderly patient’s system is less able to rebound from the rapid fluid and waste removal inherent to the dialysis process. For patients aged 80 to 84, the one-year mortality rate can be as high as 39%.
Older adults approaching ESRD typically present with multiple comorbidities, such as severe cardiovascular disease, diabetes, and hypertension, which complicate treatment. These pre-existing conditions are often worsened by the metabolic and fluid shifts of dialysis. The frequent use of five or more medications, known as polypharmacy, is also common in this group and introduces layers of risk.
Polypharmacy is an issue because many common medications are cleared by the kidneys, meaning their dosage must be constantly adjusted once dialysis begins. If drug levels are not precisely managed, medications can accumulate and cause toxic side effects, or the dialysis session can remove necessary drugs, rendering them ineffective. This delicate balance increases the likelihood of adverse drug interactions or complications during treatment.
Common Acute Complications During Treatment
Dialysis can trigger immediate and serious medical events, with intradialytic hypotension, or a sudden drop in blood pressure, being a major concern. This complication occurs because the dialysis machine removes excess fluid rapidly, which the elderly patient’s stiff arteries and weakened heart often cannot compensate for quickly enough. A sudden drop in blood pressure can lead to symptoms like dizziness, nausea, and cramping, and is poorly tolerated.
The rapid volume shifts during a dialysis session can also precipitate cardiac arrhythmias, which are abnormal heart rhythms. These events are particularly dangerous for older adults who frequently have underlying heart muscle issues, making their cardiovascular system highly sensitive to fluid and electrolyte changes. The strain on the heart is why cardiovascular events remain the leading cause of death in the dialysis population.
Complications surround the vascular access point, which is the site used to access the bloodstream for hemodialysis. Infections at the access site, whether a fistula, graft, or catheter, are a continual risk and can quickly lead to systemic infection or sepsis. The use of a central venous catheter for access is associated with an increased mortality risk compared to an arteriovenous fistula or graft.
Impact on Cognitive Function and Frailty
Chronic dialysis has a negative effect on a patient’s functional status and mental acuity. Frailty, a syndrome defined by loss of resilience and weakness, is highly prevalent in the elderly dialysis population, affecting a third or more of patients. Frailty is strongly associated with a higher risk of falls, hospitalization, and mortality after dialysis initiation.
The link between ESRD, dialysis, and cognitive impairment is a significant concern, with studies suggesting that kidney disease worsens cognitive decline. Older dialysis patients have a high risk of developing dementia, with one study finding the 10-year risk for patients aged 76 to 80 to be 28%. Cognitive impairment is independently associated with an increased risk of death.
This loss of cognitive and physical function accelerates the loss of independence, shifting the burden of the treatment onto the patient’s daily life. The time commitment of three weekly sessions, the physical exhaustion following treatment, and the strict fluid and dietary restrictions can severely limit a patient’s ability to perform activities of daily living. The result is a cycle where the treatment intended to extend life can simultaneously diminish the quality of that life.
Conservative Management and Shared Decision Making
Given the substantial risks and burdens of dialysis in the elderly, Conservative Kidney Management (CKM) is an alternative treatment path. CKM is a non-dialysis approach that focuses on intensive medical management, symptom control, and palliative care. The primary goal is maximizing comfort and quality of life by managing complications like anemia, fluid overload, and pain.
The decision to pursue CKM or dialysis requires Shared Decision Making, where the patient’s values and personal goals are central to the treatment plan. This multidisciplinary conversation involves the patient, their family, and the medical team discussing the prognosis, the potential burdens of dialysis, and the benefits of a palliative approach. Initiating these discussions early helps ensure the final choice aligns with what the patient considers a meaningful life.
For many older adults with high comorbidity and advanced frailty, CKM offers a path that avoids the acute complications and functional decline associated with dialysis. While dialysis may offer a survival advantage, this benefit must be weighed against the potential for a significantly impaired quality of life. A frank discussion based on the patient’s individual health status allows for a personalized and informed choice.