2.1. Patient Selection for CKM

2.2. Shared Decision-Making-Integrating Clinical Evidence With Patient Autonomy

3.1. HD for the Elderly: Advantages and Concerns

In-center HD offers substantial benefits for frail elderly patients compared to home-based peritoneal dialysis (PD). Key advantages include superior removal of waste products, less time required for treatment sessions, and reduced involvement needed from patients and their relatives in managing the dialysis process. In addition, attending a dialysis center allows elderly patients to engage with healthcare professionals and other patients, providing valuable social interactions that can be rare for isolated individuals [41]. However, concerns with HD for elderly patients include cardiovascular risks such as myocardial stunning, new-onset arrhythmias (including atrial fibrillation), and intradialytic hypotension, which can worsen cardiac status in frail patients [42–45]. In addition, the reliability of vascular access is an issue, as arteriovenous fistulas (AVFs) in the elderly are associated with higher rates of nonmaturation due to poor vascular caliber [46]. Consequently, central venous catheter use is higher in elderly patients, increasing the risk of infections and hospitalizations [47].

3.2. PD in the Elderly: Advantages and Concerns

PD offers several advantages for elderly patients, particularly those who are frail. It enables home-based treatment, fostering greater independence and flexibility compared to in-center HD [41]. PD integrates better with daily routines, reduces hospital visits, and avoids complications related to vascular access necessary for HD. In addition, PD helps maintain residual renal function longer, which is particularly beneficial for the elderly [48]. However, PD also has challenges. Elderly patients may find the physical demands of PD, such as handling dialysis bags and performing exchanges, difficult, especially if they have reduced manual dexterity or cognitive impairments. While the risk of peritonitis is not necessarily higher in older patients, it can have severe consequences if it occurs [49]. Assisted PD, where caregivers or healthcare workers aid with the procedure, can alleviate these issues but may not always be accessible or affordable [50].

3.3. Dialysis Targets in the Elderly and the Role of Incremental Dialysis

Traditional dialysis targets, such as achieving a specific Kt/V urea, may not be suitable for all elderly patients. Due to their often lower muscle mass, reduced physical activity, and higher prevalence of comorbidities, elderly patients may require adjusted targets that focus more on quality of life and symptom management rather than stringent biochemical goals [51]. For instance, a less aggressive fluid removal strategy can help avoid complications like intradialytic hypotension, common in older adults undergoing HD. Tailoring dialysis prescriptions to achieve minimal yet adequate solute clearance while preserving residual kidney function (RKF) is recommended for this population [52].

Incremental dialysis, where dialysis intensity is gradually increased as kidney function declines, is particularly beneficial for elderly patients. Starting HD with fewer sessions per week and gradually increasing the frequency can help maintain RKF and reduce cardiovascular events and mortality, as seen in a recent systematic review [53]. Similarly, incremental PD can start with fewer exchanges and increase based on the patient’s residual renal function and clinical status. Studies have shown that incremental PD is associated with better preservation of RKF [54], lower peritoneal glucose exposure [55], and reduced rates of PD peritonitis [56, 57]. Incremental dialysis may also foster greater patient engagement and adherence by easing them into the treatment regimen and allowing more time for adjustment.

3.4. Effect of Dialysis on Cognitive Function in the Elderly

Elderly age is an important risk factor for the high prevalence of cognitive dysfunction in patients with ESRD. High prevalence of comorbidities such as hypertension, diabetes, prior cardiovascular events, and uremia-related toxicity make this population highly vulnerable to effects of cognitive decline [58, 59]. Cognitive dysfunction in elderly ESRD patients contributes to impairment in adherence to complex medical regimes, taking informed decisions and hampers their overall participation in health care management [60]. This leads to higher mortality, hospitalizations, and poor quality of life [61]. Hemodialysis is associated with ischemic injury to the brain on account of intradialytic hypotension(IDH) [62]. IDH leads to fluctuations in cerebral perfusion, causing subclinical ischemic injury that accelerates cognitive decline. Evidence suggests that these recurrent insults disproportionately affect attention, memory, and executive function [63]. In the absence of such hemodynamic instability, PD may theoretically offer better preservation of cognitive dysfunction but randomized studies in this regard are lacking. However, data from observational studies do suggest preservation of cognitive function in patients preferring PD over shorter periods of time [64, 65]. These findings underscore the importance of personalized dialysis modality selection and the need for further longitudinal studies to optimize cognitive outcomes in this vulnerable population.

4.1. Fistula First in the Elderly and the Concerns

Elderly patients often have poor vascular health characterized by atherosclerosis and diminished vessel elasticity, complicating the surgical creation and maturation of AV fistulas. The higher prevalence of comorbidities such as diabetes and hypertension further exacerbates these difficulties, leading to increased primary failure rates and prolonged maturation times for AV fistulas [66, 67]. While AV fistulas are traditionally preferred over AV grafts due to lower infection rates and longer patency, their initial failure rates and extended maturation periods pose significant drawbacks for older patients, leading to higher catheter dependence within the first 6 months [68]. Conversely, AV grafts offer quicker maturation and higher initial success rates, making them a viable alternative for elderly patients with poor vascular health.

4.2. Strategies to Ensure Appropriate Vascular Access

4.3. Harnessing Newer Technology for Vascular Access in the Elderly

Recent advancements in endovascular techniques offer promising alternatives to traditional surgical methods, potentially reducing failure rates and improving patient outcomes [73–75]. Endovascular arteriovenous fistulas (endoAVFs) represent a significant innovation. Unlike traditional AVFs, endoAVFs like the Ellipsys Vascular Access System™ are created using minimally invasive endovascular procedures, reducing surgical trauma and associated complications, making them particularly advantageous for elderly patients with fragile vasculature and multiple comorbidities [76]. Like traditional surgically created AVFs, endoAVFs may be associated with worsening heart failure due to increased cardiac output. However, in the absence of long-term data and data from RCTs on the incidence of heart failure in patients undergoing endoAVFs, patient selection may hold the key to avoid such complications. Despite their promising results, endoAVFs may not yet be cost-effective in comparison to surgically created AVFs which is supported by a recent study from the United States (US) [77]. EndoAVFs are available only in few medical centers in North America and Europe which is an important limitation. Bioengineered blood vessels (BBVs) are emerging innovations having the potential to change the vascular access landscape. These vessels are created using tissue engineering techniques that involve culturing cells, often fibroblasts, onto biodegradable scaffolds, resulting in decellularized, biologically compatible vascular conduits [78]. A phase 2 trial in 3 centers in the US and Poland showed patency rates comparable with traditional synthetic grafts and a reduced risk of infection [79]. This is of particular interest in the elderly ESKD patients since BBVs are designed to overcome poor vascular quality. However, this will be significantly dependent on the cost barriers as well as long-term studies validating their efficacy and durability.

5.1. Malnutrition in the Elderly

Malnutrition is highly prevalent among elderly CKD patients, especially those on dialysis [80]. The prevalence of protein-energy wasting (PEW) in this population ranges from 11% to 54%, increasing with the severity of kidney disease [81]. Sarcopenia, characterized by the loss of skeletal muscle mass and strength, affects up to one-third of elderly dialysis patients, significantly contributing to malnutrition [82]. The aging process, combined with metabolic derangements of CKD, exacerbates malnutrition risk, leading to poor clinical outcomes such as increased morbidity and mortality. Several mechanisms contribute to malnutrition in elderly CKD patients, including decreased dietary intake due to anorexia driven by uremia and altered taste perception, and systemic inflammation promoting muscle protein breakdown. Inflammatory markers like C-reactive protein (CRP) and interleukin-6 (IL-6) are frequently elevated in this population, correlating with higher rates of PEW [83–85]. Dialysis itself is a catabolic process that increases protein and energy requirements while causing nutrient losses through the dialysis membrane. Other contributing factors include metabolic acidosis, hormonal changes, and comorbidities such as diabetes and gastrointestinal disturbances [86, 87].

5.2. How to Screen and Manage Poor Nutritional Status

Effective screening for nutritional status in elderly CKD and ESKD patients is essential for early identification and management of malnutrition. The National Kidney Foundation Disease Outcomes Quality Initiative (KDOQI) recommends biannual nutritional assessments using tools such as the Subjective Global Assessment (SGA) and the Malnutrition Inflammation Score (MIS) [88]. These tools evaluate dietary intake, weight changes, functional status, and physical examination findings, providing a comprehensive assessment of nutritional health. Biochemical markers such as serum albumin and prealbumin, although useful, should not be solely relied upon due to their sensitivity to non-nutritional factors. Systemic inflammation, fluid overload, acute infections, altered renal clearances can affect the levels of albumin and prealbumin [89]. Hence, an integration of clinical assessment, dietary history and laboratory parameters are essential for a comprehensive approach to diagnose malnutrition in this population.

Management of malnutrition in elderly CKD and ESKD patients involves a multifaceted approach focusing on adequate dietary intake, nutritional supplementation, and addressing underlying causes such as inflammation and metabolic acidosis. Recommended dietary protein intake for patients on dialysis is 1.0–1.2 g/kg/day, with energy intake recommendations of 25–35 kcal/kg/day [88]. Oral nutritional supplements (ONSs) in the form of branched-chain amino acids (BCAAs), protein powders with added calories, and unsaturated fat supplements have been tried in elderly dialysis patients, either as daily or intradialytic supplements [90–92]. Although albumin and prealbumin are poor markers of nutritional status when used in isolation because they are sensitive to non-nutritional factors, there is evidence that oral nutritional supplements improve these markers. These changes probably reflect broader positive shifts in nutritional and metabolic states, such as increased protein and energy intake, rather than providing an isolated measure of nutritional status. In addition, oral nutritional supplements have also been associated with increases in lean body mass, providing a more robust indication of their role in improving overall nutritional health in dialysis patients [93]. In cases where oral intake is insufficient, intradialytic parenteral nutrition (IDPN) can be considered, although its additional benefits over oral supplementation alone are limited [94, 95] (Figure 4).

6.1. Identifying Candidates for Dialysis Withdrawal

6.2. Proceeding Toward Withdrawal and Postwithdrawal Care

Withdrawing from dialysis should involve a multidisciplinary team, including nephrologists, nurses, social workers, and potentially clergy, along with the patient and their family or caregivers. This team approach facilitates shared decision-making, ensuring all stakeholders understand the patient’s values and healthcare goals [103, 104]. Effective communication and decision-making tools are essential to address both reversible and irreversible factors influencing the patient’s decision. This framework supports ethical medical practice and enhances patient and family satisfaction with end-of-life care [105]. After deciding to withdraw dialysis, comprehensive palliative care is crucial to manage symptoms and maintain quality of life in the remaining days. Supportive care includes managing physiological changes such as fluid overload, pain, nausea, and sleep disturbances [106–108]. Emotional and spiritual care provided through counseling and family support ensures a dignified end of life [109]. Providing education on the natural progression of untreated ESKD, along with clear communication about end-of-life care options, constitutes a fundamental aspect of supportive care tailored for elderly patients.