Dialysis or not in the very elderly ESRD patient

Nephrology societies and dialysis registries are reporting a dramatic increase in the number of elderly patients who require dialysis. During the last decade the number of patients starting renal replacement therapy (RRT) has increased for all ages but the increase for patients over the age of 75 years has been particularly dramatic, with a 4.3-fold rise in the USA [1]. In view of this development, it is necessary to examine more closely the quality of the results (survival, selected technique, and morbidity) of kidney replacement therapy in this age group. Despite the fact that very old patients raise the most difficult problems with respect to indication and dialysis therapy management because of their multiple comorbidities and presumed short life expectancy, there are few studies devoted to very old end-stage renal disease (ESRD) patients and their conclusions are rather discordant. Some studies report very poor survival of very old patients on dialysis, whereas others report more favorable outcomes. Moreover, specific predictive factors that could help in deciding whether dialysis would offer pre-ESRD old patients substantial prolongation of life expectancy with an acceptable quality of life are lacking [2]. Below we discuss in more depth the reasons why, in general, dialysis should not be withheld from patients above 75 years of age. Let us first consider the title of this controversy: ‘‘The dilemma of renal replacement therapy in patients over 75 years.’’ Is this actually a dilemma? Basically, a dilemma is characterized by the need to choose between two evils, or in the present case between two possibilities. If the question is posed ‘‘should 75-year-old patients be started on dialysis: yes or no?’’ it is sensible to ask the question the other way round. What could be the reasons for not providing them with dialysis? Is the survival time too short? Is the quality of life that can be achieved unsatisfactory? Are there so many old people above 75 years of age and dialysis facilities are insufficient? Do financial constraints make age a matter of rationing? Good survival on dialysis for the very old is currently well documented. Shaefer and Rohrich showed that survival in very old patients after 12 months from the start of dialysis treatment was 70.5%, and after 24 months 50.3%, and after 60 months 18.5%. These results provide no rationale for withholding dialysis treatment, even when life expectancy of over 75-year-old dialysis patients is compared with that of younger dialysis patients. In fact 75-year-old dialysis patients have a life expectancy of only 36% of age-matched healthy controlled individuals. Therefore, the remaining life time is, M. Busuioc P. Gusbeth-Tatomir A. Covic (&) Nephrology Clinic and Dialysis Center, Parhon University Hospital, ‘‘Gr.T. Popa’’ University of Medicine and Pharmacy, Carol 1st Blvd. Nr. 50, Iasi 700503, Romania e-mail: acovic@xnet.ro