Prognostication in End-Stage Kidney Disease: Tools, Evidence, and Clinical Applications

Prognostication in end-stage kidney disease is fundamental to person-centered care and shared decision-making. This review summarizes the current evidence on prognostic assessment in older adults with end-stage kidney disease who are considering dialysis or conservative kidney care. It examines the rationale for prognostication and reviews the principal clinical, functional, and laboratory predictors of mortality, including comorbidity burden, frailty, functional status, and biochemical parameters. The review discusses validated prognostic tools, including the Charlson Comorbidity Index, the Surprise Question, and multivariable prediction models, as well as emerging machine learning approaches for individualized risk prediction. It also examines the effects of functional decline, hospitalization, and limited survival benefit on treatment decisions and highlights the role of prognostic information in advance care planning and goal-concordant care. In addition, the review discusses the communication of prognosis and the practical challenges associated with implementing prognostic tools in routine nephrology practice. By integrating evidence-based prognostic assessment with individualized clinical evaluation and patient values, prognostication can support informed treatment decisions and facilitate personalized care for older adults with end-stage kidney disease.