Management of End-Stage Renal Disease in the Older Adult: Recent Advances and Future Challenges
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Introduction
End-stage renal disease (ESRD), defined as chronic renal impairment severe enough to require renal replacement therapy, is rising in prevalence worldwide, and there are currently more than 500,000 patients with ESRD in the United States.1 This number is projected to exceed 780,000 by 2020, with patients age 65 years and older representing the fastest growing component of the ESRD population.1 As such, geriatricians and other healthcare providers must be familiar with common medical issues related to the older adult with ESRD. In a previous review, we discussed management issues in older adults with chronic kidney disease (CKD; Clinical Geriatrics, December 2008). In this article, we will highlight areas of concern associated with the management of older patients on dialysis, with particular focus on recent research that has advanced overall care of this population.
Incidence, Prevalence, and Survival
In the United States, there are currently more than 175,000 dialysis patients age 65 years or older, and this population continues to grow at an alarming rate. In fact, the median age of patients starting dialysis is now 64.4 years.1 In patients age 75 years and older, the population incidence of ESRD is 1744 per million as compared to 127 per million in the 20-44 years age group, which represents a 65% increase during the past decade.1 Similar trends have been observed in developed nations worldwide.2-4
Many factors have contributed to the rising incidence of ESRD in the geriatric population, including an increased incidence of predisposing factors such as diabetes mellitus and CKD.5 Diabetes remains the leading cause of ESRD in the United States, accounting for nearly 50% of incident ESRD patients.1 Other factors include improved survival from cardiovascular and cerebrovascular disease, the more widespread availability of dialysis, earlier initiation of dialysis, and lower thresholds for accepting patients into dialysis programs.6,7
As seen with all age groups of ESRD, survival of older patients with ESRD is markedly diminished as compared to the age-matched general population (Figure). For example, U.S. adults age 65-69 years have a life expectancy of 17.2 years; the same age group of patients with ESRD has a life expectancy of only 3.9 years.1 Kurella and colleagues7 recently evaluated the clinical course and outcomes of incident ESRD patients age 80 and older. In this cohort, survival at 1 year after dialysis initiation was only 54% and did not change significantly between 1996 and 2003.7 In contrast, a recent analysis of the Canadian Organ Replacement Registry suggested a trend toward improved survival among older adults with ESRD. Focusing on incident ESRD patients age 65 and older, Jassal et al8 noted a 15-20% increase in life expectancy during the period 1995-1999 as compared to 1990-1994. In Jassal’s study, 1-year survival among incident ESRD patients age 75 or older was 69%.8 The reason for the different findings between the studies is uncertain but may reflect practice differences between the United States and Canada, particularly with regard to patient selection for dialysis.
Renal Replacement Therapy Options
The three main treatment options for ESRD are hemodialysis, peritoneal dialysis (PD), and renal transplantation. In the geriatric population, hemodialysis has traditionally been considered the most viable option.
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