The challenges of renal replacement therapy and renal palliative care in the elderly

Much of the increase in take on rate for dialysis in recent years is accounted for by older patients in whom a treatment as demanding as dialysis was previously thought to be contraindicated. The decision to dialyse the elderly often remains difficult, as recent data suggest that those with significant comorbidities are unlikely to survive more than 4-6 months longer on dialysis than they would have done if treated conservatively. It is also important to recognise that conservative treatment is not simply defined by the decision not to dialyse. Good conservative care comprises active disease management eg treatment of anaemia with erythropoietin stimulating agents and intravenous iron, and supportive care which may become increasingly complex eg pain relief with fentanyl and alfentanyl, towards the end of life. Those older patients who do decide to dialyse must contend with all the usual end of life issues facing older people, in addition to the option, denied to the rest of us, of dialysis withdrawal which effectively allows them to die at a time of their choosing