Incremental hemodialysis, a valuable option for the frail elderly patient

Management of older people on dialysis requires focus on the wider aspects of aging as well as dialysis. Recognition and assessment of frailty is vital in changing our approach in elderly patients. Current guidelines in dialysis have a limited evidence base across all age group, but particularly the elderly. We need to focus on new priorities of care when we design guidelines "for people not diseases". Patient-centered goal-directed therapy, arising from shared decision-making between physician and patient, should allow adaption of the dialysis regime. Hemodialysis (HD) in the older age group can be complicated by intradialytic hypotension, prolonged time to recovery, and access-related problems. There is increasing evidence relating to the harm associated with the delivery of standard thrice-weekly HD. Incremental HD has a lower burden of treatment. There appears to be no adverse clinical effects during the first years of dialysis in presence of a significant residual kidney function. The advantages of incremental HD might be particularly important for elderly patients with short life expectancy. There is a need for more research into specific topics such as the assessment of the course of frailty with progression of chronic kidney disease and after dialysis initiation, the choice of dialysis modality impacting on the trajectory of frailty, the timing of dialysis initiation impacting on frailty or on other outcomes. In conclusion, understanding each individual's goals of care in the context of his or her life experience is particularly important in the elderly, when overall life expectancy is relatively short, and life experience or quality of life may be the priority.