Hemodialysis in the older adult
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
In the United States, the primary treatment of older end-stage renal disease (ESRD) patients (greater than 75 years of age) is in-center hemodialysis (96 percent) . Continuous ambulatory peritoneal dialysis (CAPD) or continuous cycler peritoneal dialysis (CCPD) account for approximately 3.5 percent, while only 0.3 percent are treated with home hemodialysis .
The average age of the patient undergoing dialysis in the United States has been steadily increasingly over the last several decades. In 2000, the average age was approximately 62 years .
The number of older patients initiating dialysis is also increasing. In a survey using the United States Renal Data System (USRDS) database, the number of patients 80 years of age and older who initiated dialysis increased from 7054 in 1996 to 13,577 individuals in 2003 . After adjustment for population growth, the rate of dialysis initiation had increased by 57 percent over this time period. However, older patients may be less likely to be started on dialysis, compared with younger patients with a similar degree of kidney dysfunction. This was suggested by a community-based cohort study of over 1.8 million adults in Alberta, Canada . At a follow-up of 4.4 years, among patients who had an estimated glomerular filtration rate (GFR) of 15 to 29 mL/min/1.73 m2 at the beginning of the study, the rate of untreated kidney failure (defined as estimated GFR <15 mL/min/1.73 m2) was over fivefold greater for patients older than 85 years of age, compared with those 18 to 44 years. The individual reasons for withholding dialysis cannot be determined from this study .
Important points to consider when evaluating the treatment of older patients with ESRD include:
●The life expectancy of such patients
- Excerpts from the USRDS 2005 annual data report: Atlas of end-stage renal disease in the United States. Am J Kidney Dis 2006; 47 (Suppl 1):S1.
- Hansberry MR, Whittier WL, Krause MW. The elderly patient with chronic kidney disease. Adv Chronic Kidney Dis 2005; 12:71.
- Kurella M, Covinsky KE, Collins AJ, Chertow GM. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med 2007; 146:177.
- Hemmelgarn BR, James MT, Manns BJ, et al. Rates of treated and untreated kidney failure in older vs younger adults. JAMA 2012; 307:2507.
- Kurella Tamura M, Winkelmayer WC. Treated and untreated kidney failure in older adults: what's the right balance? JAMA 2012; 307:2545.
- Excerpts from the USRDS 2009 annual data report: Atlas of end-stage renal disease in the United States. Am J Kidney Dis 2010; 55 (Suppl 1):S1.
- Létourneau I, Ouimet D, Dumont M, et al. Renal replacement in end-stage renal disease patients over 75 years old. Am J Nephrol 2003; 23:71.
- Jassal SV, Trpeski L, Zhu N, et al. Changes in survival among elderly patients initiating dialysis from 1990 to 1999. CMAJ 2007; 177:1033.
- Ahmed S, Addicott C, Qureshi M, et al. Opinions of elderly people on treatment for end-stage renal disease. Gerontology 1999; 45:156.
- Mignon F, Michel C, Mentre F, Viron B. Worldwide demographics and future trends of the management of renal failure in the elderly. Kidney Int Suppl 1993; 41:S18.
- Westlie L, Umen A, Nestrud S, Kjellstrand CM. Mortality, morbidity, and life satisfaction in the very old dialysis patient. Trans Am Soc Artif Intern Organs 1984; 30:21.
- Tapson JS, Rodger RS, Mansy H, et al. Renal replacement therapy in patients aged over 60 years. Postgrad Med J 1987; 63:1071.
- Schaefer K, Asmus G, Quellhorst E, et al. Optimum dialysis treatment for patients over 60 years with primary renal disease. Survival data and clinical results from 242 patients treated either by haemodialysis or haemofiltration. Proc Eur Dial Transplant Assoc Eur Ren Assoc 1985; 21:510.
- Williams AJ, Antao AJ. Referral of elderly patients with end-stage renal failure for renal replacement therapy. Q J Med 1989; 72:749.
- Park MS, Lee HB. Outcome of dialysis in the elderly. Geriatr Nephrol Urol 1992; 1:173.
- Panarello G, De Baz H, Cecchin E, Tesio F. Dialysis for the elderly: survival and risk factors. Adv Perit Dial 1989; 5:49.
- Ismail N, Hakim RM, Oreopoulos DG, Patrikarea A. Renal replacement therapies in the elderly: Part 1. Hemodialysis and chronic peritoneal dialysis. Am J Kidney Dis 1993; 22:759.
- Triolo G, Segoloni GP, Salomone M, et al. Comparison between two dialytic populations undergoing renal transplantation. Adv Perit Dial 1990; 6:72.
- Wall J. Dialysis in the elderly. Some UK experience. Adv Perit Dial 1990; 6:82.
- Battelle Human Affairs Research Centers. National Kidney Dialysis and Kidney Transplantation Study, Seattle, WA, 1985.
- Evans RW, Manninen DL, Garrison LP Jr, et al. The quality of life of patients with end-stage renal disease. N Engl J Med 1985; 312:553.
- Ifudu O, Mayers J, Matthew J, et al. Dismal rehabilitation in geriatric inner-city hemodialysis patients. JAMA 1994; 271:29.
- Byrne C, Vernon P, Cohen JJ. Effect of age and diagnosis on survival of older patients beginning chronic dialysis. JAMA 1994; 271:34.
- Murtagh FE, Marsh JE, Donohoe P, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22:1955.
- Kurella Tamura M, Covinsky KE, Chertow GM, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009; 361:1539.
- Carson RC, 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 2009; 4:1611.
- Röhrich B, Asmus G, von Herrath D, Schaefer K. Is it worth performing kidney replacement therapy on patients Over 80? Nephrol Dial Transplant 1996; 11:2412.
- Peri UN, Fenves AZ, Middleton JP. Improving survival of octogenarian patients selected for haemodialysis. Nephrol Dial Transplant 2001; 16:2201.
- Joly D, Anglicheau D, Alberti C, et al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. J Am Soc Nephrol 2003; 14:1012.
- O'Hare AM. Vascular access for hemodialysis in older adults: a "patient first" approach. J Am Soc Nephrol 2013; 24:1187.
- DeSilva RN, Patibandla BK, Vin Y, et al. Fistula first is not always the best strategy for the elderly. J Am Soc Nephrol 2013; 24:1297.
- Hinsdale JG, Lipcouritz GS, Hoover EL. Vascular access in the elderly: Results and perspectives in a geriatric population. Dial Transplant 1985; 14:560.
- Dialysis access in patients older than 65 years. In: Vascular Access for Hemodialysis, 2 ed., Sommer BG, Henry, ML (Eds), W L Gore and Assoc, 1991. p.166.
- Brunner FP, Brynger H, Chantler C, et al. Combined Report on Regular Dialysis and Transplantation in Europe, IX, 1978. Proc Eur Dial Transplant Assoc 1979; 16:4.
- Windus DW, Jendrisak MD, Delmez JA. Prosthetic fistula survival and complications in hemodialysis patients: effects of diabetes and age. Am J Kidney Dis 1992; 19:448.
- Pourchez T, Moriniere P, St. Priest A. Outcome of vascular access for hemodialysis in the elderly (>75 years) (abstract). Proc Eur Dial Transplant Assoc 1990; 27:160.
- Porush JD, Faubert PF. Chronic renal failure. In: Renal Disease in the Aged, Little, Brown, Boston 1991. p.285.
- Palder SB, Kirkman RL, Whittemore AD, et al. Vascular access for hemodialysis. Patency rates and results of revision. Ann Surg 1985; 202:235.
- Lok CE, Oliver MJ, Su J, et al. Arteriovenous fistula outcomes in the era of the elderly dialysis population. Kidney Int 2005; 67:2462.
- Lazarides MK, Georgiadis GS, Antoniou GA, Staramos DN. A meta-analysis of dialysis access outcome in elderly patients. J Vasc Surg 2007; 45:420.
- Peterson WJ, Barker J, Allon M. Disparities in fistula maturation persist despite preoperative vascular mapping. Clin J Am Soc Nephrol 2008; 3:437.
- de Leur K, Oztürk C, Van Zeeland ML, et al. Vascular access outcome in the elderly dialysis patient in combination with the quality of life. Vasc Endovascular Surg 2013; 47:444.
- Hod T, Patibandla BK, Vin Y, et al. Arteriovenous fistula placement in the elderly: when is the optimal time? J Am Soc Nephrol 2015; 26:448.
- Dixon BS. Timing of arteriovenous fistula placement: keeping it in perspective. J Am Soc Nephrol 2015; 26:241.
- Murea M, James KM, Russell GB, et al. Risk of catheter-related bloodstream infection in elderly patients on hemodialysis. Clin J Am Soc Nephrol 2014; 9:764.
- Maiorca R, Vonesh EF, Cavalli P, et al. A multicenter, selection-adjusted comparison of patient and technique survivals on CAPD and hemodialysis. Perit Dial Int 1991; 11:118.
- Lupo A, Cancarini G, Catizone L, et al. Comparison of survival in CAPD and hemodialysis: a multicenter study. Adv Perit Dial 1992; 8:136.
- Nelson CB, Port FK, Guire KE. Dialysis patient survival: Evaluation of CAPD vs hemodialysis using 3 techniques. Perit Dial Int 1992; 12:144.
- Bloembergen WE, Port FK, Mauger EA, Wolfe RA. A comparison of mortality between patients treated with hemodialysis and peritoneal dialysis. J Am Soc Nephrol 1995; 6:177.
- Winkelmayer WC, Glynn RJ, Mittleman MA, et al. Comparing mortality of elderly patients on hemodialysis versus peritoneal dialysis: a propensity score approach. J Am Soc Nephrol 2002; 13:2353.
- Jaar BG, Coresh J, Plantinga LC, et al. Comparing the risk for death with peritoneal dialysis and hemodialysis in a national cohort of patients with chronic kidney disease. Ann Intern Med 2005; 143:174.
- Foley RN, Parfrey PS, Harnett JD, et al. Mode of dialysis therapy and mortality in end-stage renal disease. J Am Soc Nephrol 1998; 9:267.
- Bloembergen WE, Nelson CB, Port FK. Outcomes of CAPD versus hemodialysis in the elderly. In: Nephrology and Urology in the Aged Patient, Oreopoulos DG, Mchelis MF, Herschorn S (Eds), Kluwer Academic Publishers, Amsterdam 1993. p.251.
- Posen GA, Fenton SS, Arbus GS, et al. The Canadian experience with peritoneal dialysis in the elderly. Adv Perit Dial 1990; 6:47.