Clinical challenges and individualized approaches to dialysis therapy in older adults

Global population aging has substantially increased in the number of older adults who undergo kidney replacement therapy (KRT). Age-related physiological changes and functional dependence in this population lead to the multifaceted clinical and ethical challenges associated with KRT. Geriatric syndromes, including functional impairment, frailty, malnutrition, and multimorbidity, can influence the choice of dialysis modality and modify dialysis prescriptions, often resulting in patients requiring assistance with dialysis implementation. Although dialysis remains a key life-sustaining therapy, the limited life expectancy and multiple comorbidities of older adults increase the risk of adverse outcomes, supporting the consideration of conservative kidney management as an alternative. Furthermore, because many older adults prioritize quality of life and reduced treatment burdens over longevity and biochemical targets, dialysis-related decisions should be tailored to individual preferences and goals. Shared decision-making involving older patients, their caregivers, healthcare professionals, and nephrologists is essential for determining the most appropriate treatment approach. This review addresses the clinical considerations in decision- making regarding dialysis and proposes optimal treatment strategies tailored to the unique needs of older patients with chronic kidney disease.