[End stage renal failure in the elderly. A therapeutic dilemma]

During the last 20 years the world population has aged at an exponential rate. At present, more than 35% of patients starting renal replacement therapy (RRT) in Europe are more than 75 years old. Several factors have contributed to this increment. The attitude towards chronological age as a factor in therapeutic decisions has changed. Modern techniques make dialysis better tolerated and effective treatments of anemia and mineral metabolism are available. The increased incidence of diabetic nephropathy, vascular diseases, endovascular procedures, congestive heart failure and use of nephrotoxic drugs are all frequent causes of RRT in the elderly. The results of RRT in the very elderly in terms of survival, morbidity and quality of life are unclear. The 1-year survival according to large registries like the USRDS and the EDTA-ERA Registry is 54-66%. Important comorbid conditions are frequent and the mortality from all causes is more than twofold that observed in the general population of the same age. Failure of vascular access surgery is common and the accepted guidelines are probably inapplicable to most elderly patients. Yet neither the KDOQI nor the EBPG consider the demographic aspect in their recommendations. Elderly patients are less frequently treated with peritoneal dialysis, possibly because the potential advantages of this technique are contrasted with perceived barriers due to physical handicaps, social and financial difficulties and housing problems. In most countries, old age is a practical obstacle to inclusion of patients in kidney transplantation waiting lists. This situation is slowing changing, however. In Europe, for instance, the Eurotransplant Senior Program ''Old For Old'' has been implemented during the last decade. The results, albeit limited, are encouraging. Because of the uncertainties regarding prognosis and quality of life and the difficulties of dialysis treatment, the alternative of continuing conservative treatment is often considered by elderly patients and their families. Based upon appropriate diet and active treatment of complications, conservative treatment may give results comparable to those of dialysis in selected and cooperative patients.