Treatment of chronic kidney disease in the elderly: diet or conservative management

The elderly constitute the fastest-growing group of patients reaching end-stage renal disease and requiring renal replacement therapy. In this group of patients renal failure is only one of the many comorbidities affecting them, and for the nephrologist the decision whether to commence renal replacement therapy when patients present multiple comorbidity is a challenge. In fact, many elderly patients with severe comorbidity have a poor prognosis once dialysis is started, and a conservative management or a low protein diet can be less harmful. Information on survival of elderly patients on these therapies is limited, but in the last years a large body of literature has been published in this field. Rates of dialysis withdrawal are highest among the oldest patients, raising the possibility that the standard information given to patients for dialysis warrant an age-sensitive approach. For the elderly, the information should include risk, benefit and burden associated with dialysis, age-specific estimates of prognosis with dialysis or with conservative management, and potential for loss of independence and decline in functional status and cognitive impairment. Dialysis can impair quality of life of the elderly, and when decision makers choose a treatment they have to keep in mind that specialists should add life to years, and not years to life. When a "no dialysis" option is chosen, an active renal disease management as treatment of anemia, acidosis, fluid balance, hypertension, and active end of life care is required. This approach requires devoted attention from patients, families and caregivers, and a multi-disciplinary approach.