Kidney replacement therapies in the older person: challenges to decide the best option

A multitude of challenges exist when supporting older adults in deciding on the optimal kidney replacement therapy (KRT), including frailty, comorbidity, cognitive impairment, dialysis modality, as well as local availability of services. The combination of these factors can determine treatment outcomes and quality of life (QoL), and as such the care of older people should be tailored to take these into account. Frailty in older people with chronic kidney disease (CKD) leads to higher rates of hospitalization, increased mortality, and a diminished QoL, while cognitive impairment, present in up to 50% of people with CKD, exacerbates these challenges and affects decision making. Dialysis, particularly haemodialysis, can accelerate physical and cognitive decline in frail older adults. Conversely, peritoneal dialysis (PD) presents a home-based alternative that may better support QoL, particularly for people wanting to prioritize treatment flexibility and independence. Assisted PD programmes have emerged as a valuable option for older people who cannot manage home-based care independently, improving access to KRT. Ultimately shared decision making should be employed when discussing KRT, incorporating patient goals, prognostic awareness, and QoL measures. There is also the emerging role of the geriatrician and the need for an integrated Comprehensive Geriatric Assessment. These elements support older adults to make informed choices that align with the individuals' values and health needs. In designing future health services to meet the needs of increasing numbers of older people, there needs to be increased access to assisted PD as well as multidisciplinary working to ensure patient-focused care surrounding KRT in older adults.