HE OR DP EN ANCIANOS

1. Peritoneal or hemodialysis for the frail elderly
patient, the choice of 2 evils?
Edwina A. Brown1
, Frederic O. Finkelstein2
, Osasuyi U. Iyasere1
and Alan S. Kliger3
1
Imperial College Kidney and Transplant Centre, Hammersmith Hospital, London, United Kingdom; 2
Yale School of Medicine, New Haven,
Connecticut, USA; and 3
Yale School of Medicine and Yale New Haven Health System, New Haven, Connecticut, USA
Management of older people on dialysis requires focus
on the wider aspects of aging as well as dialysis. Almost all
frail and older patients receiving dialysis will default to
in-center hemodialysis, although the availability of assisted
peritoneal dialysis enables dialysis at home. As with any
disease management decision, patients approaching end-
stage renal disease need all the appropriate facts about
their prognosis, the natural history of their disease without
dialysis, and the resulting outcomes and complications of
the different dialysis modalities. Hemodialysis in the older
age group can be complicated by intradialytic hypotension,
prolonged time to recovery, and vascular access–related
problems. Peritoneal dialysis can be difficult for older
patients with impaired physical or cognitive function and
can become a considerable burden. Use of incremental
dialysis, changes in hemodialysis frequency, and delivery
and use of assistance for peritoneal dialysis can ameliorate
quality of life for older patients. 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. Indeed,
some patients select the option of no dialysis or
conservative care. With multifaceted assessments of
care, physicians should be able to give individual patients
the ability to select and continue to make the best
decisions for their care.
Kidney International (2017) 91, 294–303; http://dx.doi.org/10.1016/
j.kint.2016.08.026
KEYWORDS: geriatric nephrology; hemodialysis; peritoneal dialysis
Copyright ª 2016, International Society of Nephrology. Published by
Elsevier Inc. All rights reserved.
“T
he good physician treats the disease. The great
physician treats the patient who has the disease.” So
wrote Sir William Osler more than a century ago.1
This observation is even more pertinent today with an
aging population. The impact of aging on health and the
response to illness is not, however, related to chronological
years. Other factors associated with aging, such as the number
of comorbidities and overall day-to-day functioning, both
physically and mentally, and frailty, have a much greater role
in determining outcomes and life expectancy, and therefore
need to be assessed. Many interventions, including dialysis,
can have a considerable negative impact on the day-to-day
living of individuals and their families, but yet may be of
benefit in alleviating some symptoms and sometimes
extending life. Given the potential distress to patients and
their families as well as the cost of these interventions, it is not
surprising that there is now considerable debate in the lay and
medical press about quality or quantity of life for individuals
with limited life expectancy.
Nephrology is not immune to this debate. The incidence of
end-stage renal disease is highest in the >75-year-old age
group.2,3
In France, for example, 39% prevalent dialysis
patients are older than 75 years of age.4
Over the past few
years, however, there has been mounting concern that older
frail patients can have very poor outcomes on dialysis.5
It has
therefore been suggested that dialysis should be regarded as
part of an overall management plan with the goals of the
dialysis component being tailored to the needs of the older
patient.6,7
For example, an increasing number of patients are
started on dialysis for heart failure while still having signifi-
cant residual renal function. Dietary protein and sodium
intake, physical activity, and energy expenditure, all of which
will be low, will affect the rate of generating metabolic waste.
The dialysis clearance target may therefore be lower than that
required for younger, more active patients.
As a population, older dialysis patients may present later
for dialysis,8
have a greater number of comorbid conditions,
are at greater risk of cognitive dysfunction,9
and have
increased levels of frailty10,11
and potential sensory impair-
ments.12
Socially, this may lead to increased difficulty coping
at home alone due to functional and psychological
dependencies13
with a larger burden on patients’ caregivers,
or, alternatively, patients may sometimes be caregivers them-
selves.14
It is perhaps not surprising that the propensity for
functional limitations and challenging social circumstances has
traditionally curtailed the self-care dialysis treatment options
Correspondence: Edwina A. Brown, Hammersmith Hospital, Du Cane Road,
London W12 0HS, United Kingdom. E-mail: e.a.brown@imperial.ac.uk
Received 15 June 2016; revised 5 August 2016; accepted 8 August 2016;
published online 20 October 2016
review www.kidney-international.org
294 Kidney International (2017) 91, 294–303

2. available to older patients. Almost all frail and older patients
receiving dialysis will default to in-center hemodialysis (HD).
In the United Kingdom, only 11.3% of prevalent dialysis pa-
tients 75 years of age and older are on peritoneal dialysis (PD)
compared with 21.1% in those younger than 55 years of age.15
Similarly, in the United States, 5.5% prevalent dialysis patients
75 years of age and older are on PD compared with 8.7% in the
22–44-year-old age group.3
This pattern is replicated in many
European countries with patients 70 years of age and older
being 56% less likely to receive PD than those in the 20- to
44-year-old age group.16
Yet, in response to a questionnaire at
the British Renal Society meeting in July 2015, only 7 of 114
individuals agreed with the statement “hemodialysis is the
optimal dialysis modality for older people” (E. Brown, personal
observation).
Impact of frailty on outcomes
We need to understand the concept of frailty to consider why
and when goals of care and medical interventions for in-
dividuals as they age should differ from those who are
younger and fitter. Clinically, frailty presents as a composite of
poor physical function, exhaustion, low physical activity, and
weight loss and is associated with an increased risk of falls,
cognitive impairment, hospitalization, and death.17
A pre-
dictive measure of frailty can easily be assessed by clinicians
and is based on clinical judgment of the patient’s fitness and
dependence on others.18
Frailty has been recognized as being
more common in the CKD population independent of age for
some years.10,11
More recent studies have shown that similar
to the general population, frailty in predialysis and dialysis
patients is associated with increased cognitive dysfunction19
and mortality.20–22
A cross-sectional analysis of the baseline
data in the FEPOD (Frail Elderly Patient Outcomes on
Dialysis) study recently showed that frailty is also associated
with worse quality of life (QoL) scores for patients on dialysis,
independent of modality. Hospitalization rates (>40% in the
previous 3 months) were high and falls (one-third of patients
in the previous 6 months) were common in this group of
patients.23
Goals of treatment on dialysis
Determination of the degree of frailty enables the clinician to
evolve a holistic treatment plan (Table 1). When considering
dialysis, however, discussions often focus on “saving” life
rather than prognosis and life expectancy or QoL. Yet there is
ample evidence that individuals with limited life expectancy
are mostly more concerned about quality rather than quantity
of life.24,25
Survival outcomes in older dialysis patients are
generally poor. The median life years after starting dialysis (all
modalities), in patients older than 75 years of age is 2 years
according to UK registry data.2
US Renal Data System data
show that the adjusted survival rate for the same age group is
62.5% at 1 year and 17.1% at 5 years.3
Not surprisingly,
mortality rates increase with advancing age.26
Decisions about
dialysis modality or even dialysis or no dialysis should be
made by the patient with or without the wider family unit
depending on the individual’s wishes and culture.27
Under-
standing the impact of this decision on the patient and his or
her family needs to be considered. As with any disease
management decision, patients approaching end-stage renal
disease need all the appropriate facts about their prognosis,
the natural history of their disease without dialysis, and the
resulting outcomes and complications of the different dialysis
modalities.28
Predicting prognosis. Informing patients accurately about
prognosis is key to individualizing dialysis and associated
supportive care. Physicians are often not good at doing this,
with quotes in recent literature such as “if you’re on dialysis
you could last 10, 15, 20 years (male 76 years old)” or “you
will probably have six years on dialysis (male 82 years old).”29
The first report of octogenarians on dialysis included some
prognostic markers with patients who were malnourished and
with poor physical function and multiple comorbidities
having the worst survival.30
Subsequent analyses from
American and European registry data have used multiple
clinical factors to predict survival for patients starting on
dialysis; these have included comorbidities, biochemical
measurements, dialysis-related factors, and mobility.31–34
Determination of a risk score reflects the median for the
population to which the individual belongs and not a pre-
diction for the individual patient. It does enable, however,
objective stratification of individuals starting dialysis into
low-, medium-, or high-risk groups of early mortality and
therefore considering appropriate support and informed
decision making.31
Outcomes of HD compared with PD. Given the limited life
expectancy of frail older patients on any dialysis modality, the
important comparison is QoL. Most of the comparative data
available, however, are based on mortality, as this is easily
extractable from registries. The North Thames Dialysis study,
Table 1| Clinical considerations for dialysis in frail patients
Dialysis parameters
Timing of dialysis initiation
Hemodialysis related issues
Dosage: incremental, conventional (3 times per week), more frequent,
or nocturnal
Intradialytic hypotension and associated ischemic problems
Transport requirements to attend dialysis sessions
Vascular access
Time to recovery
Peritoneal dialysis
Dosage: incremental or conventional (daily)
Ability of patient to learn technique
Need for and availability of assistance to perform dialysis
Need for social support from family or community
Potential impact on
Symptom burden
Quality of life
Physical function
Cognitive impairment
Falls
Nutritional status
Dependence
Social support networks
EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient review
Kidney International (2017) 91, 294–303 295

3. which is the only published prospective longitudinal study of
older individuals on dialysis, compared survival outcomes of
HD and PD patients older than 70 years of age; there were no
differences in the mortality risk at 12 months.35,36
In 2011,
the UK National Institute for Health and Care Excellence
concluded in its guideline on PD (all ages) that “very-low-
quality evidence (from one RCT and 17 national registries)
showed a tendency for no difference in long-term mortality in
adults and undergoing peritoneal dialysis compared with
those on hemodialysis.”37
More recently, a meta-analysis of
observational studies (total number of patients >631,421)
including a Korean cohort of 13,065 incident older dialysis
patients found a higher risk of death in PD patients with the
survival advantage being more pronounced in patients with
diabetes and a longer dialysis vintage.38
However, there was
significant heterogeneity among the included observational
studies and no information about frailty, which, as we have
discussed, can have a significant impact on mortality rate.39
Interestingly, in France, where frail older patients in some
districts are preferentially offered PD (assisted), data from the
French Peritoneal Dialysis Registry for 1615 patients older
than 75 years of age showed that the median survival for those
requiring nurse assistance (80% of the cohort) is 24
months,40
which is very similar to that for all comers (90% of
whom would be on HD) in the United Kingdom renal reg-
istry data.2
Focusing on registry-derived mortality compari-
sons between dialysis modalities is, however, the wrong
question.39,41
Survival rates for the frail elderly are poor on
any dialysis modality, and, as recent studies have shown, for
those older than 80 years of age or those with poor physical
function or multiple comorbidities, there may not be even
any survival advantage having any type of dialysis.42–44
The
purpose of dialysis, however, is survival with fulfillment of the
goals of care, so starting dialysis is still appropriate if the goal
is to be less short of breath and therefore spend more time
with the family, but maybe not if it is at the expense of
becoming more functionally dependent and no longer being
able to live independently.
QoL has been shown to influence decisions regarding
renal replacement therapy. Studies have shown that patients
are willing to forego years of survival for more time away
from the hospital,45
and when life expectancy is perceived to
be short, a surprisingly high percentage of patients on HD
would choose supportive rather than interventional treat-
ment.46
Three observational studies specifically compared
QoL outcomes of older patients on HD and those on PD.
The North Thames Dialysis study used the Short Form-36
and KDQOL (Kidney Quality of Life) survey to assess QoL
in 174 older patients. Although the PD group had higher
KDQOL at baseline compared with HD patients, there was
no difference in QoL measures at 6 and 12 months.35
The
BOLDE (Broadening Options for Long Term Dialysis in the
Elderly) study assessed QoL in 140 patients 65 years of age
and older. The PD patients had significantly lower illness
intrusion compared with HD patients. There were no sig-
nificant differences in other QoL measures.47
More recently,
the FEPOD study compared QoL between older dependent
patients on assisted PD and matched patients on HD
(N ¼ 251). Treatment satisfaction was higher in PD patients,
but there were no differences in other measures of QoL
between the groups.23
Another important comparison is how HD and PD affect
specific aging-related syndromes related to physical and
cognitive impairment. The risk of problems associated with
aging is considerably higher than in the general population
for both HD and PD, but there appear to be some differences
between the 2 modalities. For instance, using Medicare claims
data, there is suggestive evidence that PD may be associated
with a lower cumulative risk of dementia compared with HD,
even after adjusting for lower vascular comorbidity in the PD
population.48
The risk of subdural hematomas49
and hem-
orrhagic strokes may also be lower in PD patients compared
with HD patients.50
In contrast, Farragher et al.51
recently
reported an equivalent risk of falls between older patients on
HD and those on PD in a prospective cohort of 236 older
patients.
HD: advantages and disadvantages for the elderly
As shown in Table 2, HD for the frail elderly presents chal-
lenges, and the clinician, patient, and patient’s family need to
balance the advantages and disadvantages of the therapy as
well as the potential modifications of the standard 3 times
weekly HD treatment regimen.52
Recent literature has focused
attention on some of the negative aspects of HD that
potentially could have more adverse effects on frail, elderly
patients than in younger, healthier patients.53–62
Specific
concerns for the elderly with HD involve the association of
HD with hypotension, the impact of HD on myocardial and
cerebral functioning, the risks of increasing inflammatory
markers, the challenges of creating vascular access, the
problem of postdialysis recovery time, and the risks of falls
after dialysis.
HD, particularly when delivered to a uniform standard
evolved for younger and fitter patients, is frequently associ-
ated with hypotension, which can be a major cause of
morbidity in elderly HD patients.53,54
A recent study of 1137
patients with w45,000 treatments that defined intradialytic
hypotension (IH) as a decrease in blood pressure of >30
mm Hg to a systolic blood pressure to <90 mm Hg noted that
17% of treatments were associated with IH and that IH
developed in 75% of patients over the course of 1 year.54
Patients with >35% IH treatments had poorer survival
(P ¼ 0.036) and more frequent and longer hospitalizations
(P ¼ 0.04 and P ¼ 0.002, respectively) than patients without
IH. Importantly, there was a strong association of hypotensive
episodes with advancing age. The development of IH has been
associated with several major problems, which are of partic-
ular concerns in elderly patients.55,56
The problems of
myocardial stunning and regional wall motion abnormalities
developing during an HD session are now well documented.
These changes are associated with dialysis-related hypoten-
sion and increased mortality rates. Importantly, HD-induced
review EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient
296 Kidney International (2017) 91, 294–303

4. myocardial stunning may progress over 1 year with the
development of regional fixed systolic dysfunction, suggesting
underlying myocardial hibernation and fibrosis.56
Long-term HD treatments have also been associated with
progressive cerebral atrophy with a pattern of ischemic brain
injury when assessed by magnetic resonance imaging tech-
niques.57–59
These changes have been associated with cogni-
tive impairment when patients have neuropsychiatric testing.
These ischemic changes appear to be associated with hemo-
dynamic instability during the HD treatment.58
Initiation of maintenance HD treatment has been associ-
ated with marked (>3-fold) increases in circulating endo-
toxin levels, which has been attributed to gut hypoperfusion,
with the highest levels being statistically associated with a
maximum reduction in both systolic and diastolic blood
pressure during HD (r ¼ 0.45, P ¼ 0.032).60
In this study,
circulating endotoxemia was most notable in those with the
highest cardiovascular disease burden. Furthermore, pre-
dialysis endotoxin correlated with dialysis-induced hemody-
namic stress (ultrafiltration volume, relative hypotension) and
myocardial stunning and was strongly associated with an
increased risk of death (P ¼ 0.034).
Postdialysis recovery time (the length of time that it takes a
patient to recover from a dialysis session) is well documented
and is another factor affecting the dialysis experience for older
patients. The average recovery time is >6 hours for patients
maintained on conventional 3 times weekly HD, with 68% of
patients taking $2 hours to recover.61,62
A strong association
with age was noted in the recent DOPPS (Dialysis Outcomes
and Practice Patterns Study). Importantly, the postdialysis
recovery time is associated with impairments in various
health-related QoL measures; this is of particular concern for
the frail elderly patient.
Creation of vascular access is a key component of HD, but
in the elderly, it can present problems because of underlying
vascular and cardiac disease. Success rates for arteriovenous
fistulae vary in the elderly, although some reports note that
success rates in patients older than 80 years of age can be as
good as those in younger patients. A higher percentage of
central venous catheters is used in elderly patients, which
increases the risk of infections and mortality.63–65
The im-
pacts of lower arteriovenous fistula success and lower life
expectancy mean that the advantages of a “fistula-first” policy
for frail older patients may be less than in younger and fitter
patients.65
This was reflected in a recent position paper from
the Vascular Access Working Group of the Italian Society of
Nephrology that states that no approach to vascular access can
be expected to meet the needs of all older adults with
advanced kidney disease. Their recommendation is that the
decision should be made after a careful multidisciplinary
assessment of the patient including a vascular assessment,
should be guided by the patient’s preferences and the sur-
geon’s experience, and based on balanced an unbiased
information.66
Transportation to and from the dialysis facility can present
problems, particularly for frail elderly patients with limited
Table 2| Hemodialysis and peritoneal dialysis for older
patients
Hemodialysis Peritoneal dialysis
Patient perspective
Advantages
Dialysis procedure done by
others
Social structure related to
attending dialysis unit
Regular medical review when
attending dialysis
Advantages
Home-based treatment so more
patient independence
Fits in with social activities
Can be done by carer (family or
paid assistant)
Fewer hospital visits
Does not require vascular access
Flexibility of treatment: CAPD or
APD
Can have days off if residual
renal function
Easier to travel for holidays or to
visit family
Disadvantages
Impact of therapy on quality of
life
Can interfere with social and
family life
Transport (journey and waiting
time) needs to be added into
treatment time
Prolonged recovery time; many
feel washed out for hours
after dialysis session
Difficult to travel for holidays or
to visit family
Vascular access can be difficult to
establish and maintain and
may require multiple
procedures
Disadvantages
Impact of therapy on quality of
life
Has to do procedure (or have
assistance)
Needs space to store dialysis
supplies
Treatment burden; repetitive
nature of PD
Fear of infection and peritonitis
Physician perspective
Advantages
Familiar with HD; complications
often regarded as part of
treatment
Well-established pathways to
start patient on HD so easy to
organize
Very few medical contraindica-
tions so less need to assess
patient for medical and psy-
chosocial eligibility
Ease of achieving “adequate
dialysis”
Advantages
Patient independence on home
treatment
Avoids hemodynamic
disturbance
Prolongation of residual renal
function
Flexibility of CAPD and APD
Disadvantages
Risk of intradialytic hypotension
Vascular access may be difficult
Risk of infection with central
venous access
Transport needs may add to cost
Loss of residual renal function
Disadvantages
Often not familiar with PD and
only see patients with
complications
Perception that older patients
cannot do PD so not offered
Risk of infection
Risk of technique failure due to
infection or inadequate
clearance or ultrafiltration
once anuric
APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal dial-
ysis; HD, hemodialysis.
EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient review
Kidney International (2017) 91, 294–303 297

5. mobility, but is rarely addressed in the medical literature.
The organization of transportation can indeed be chal-
lenging and expensive to health care systems and individual
patients.67,68
The need for transport not only adds to treat-
ment times, but is also disruptive to standard daily routines
for patients, particularly those who require stretchers,
patients with dementia who can become disoriented, and
when considering the often antisocial hours of dialysis
sessions.
Having cited the problems with HD for the frail elderly
patient, there are certain advantages that should be noted.
The advantages of in-center HD over home-based peritoneal
dialysis treatment for the frail elderly include efficient solute
removal, limited time spent for dialysis, and freedom for the
patient and his or her family from involvement with the
dialysis procedure itself. In addition, there is the advantage of
socialization with staff and other patients at the dialysis fa-
cility, a distinct advantage for elderly patients who may be
isolated and have limited social contact. Furthermore, there is
the advantage of having frequent contact with the dialysis staff
to provide both medical and psychosocial support for the
patient.63
What about the amount of dialysis that should be pre-
scribed for the frail older patient? The standards of care in
the United States (and in many other countries as well) are
summarized in the National Kidney Foundation KDOQI
Guidelines.69
These suggest that dialysis facilities should
target a minimally adequate dose as measured by Kt/V urea
of 1.2 per HD treatment given 3 times per week. This dose is
the target set independent of patient age, frailty, or
comorbidities. Achieving this target generally requires w4
hours of treatment. Even this can pose problems for some
older patients, many of whom have arthritis and therefore
may have difficulty sitting in the dialysis chair for the
duration of treatment.
Should the dialysis prescription be modified for the frail
older patient? Is it appropriate to “dry out” an older patient to
the same extent as a younger patient with the associated risk
of intradialytic hypotension, myocardial stunning, and cere-
bral ischemia? The resulting loss of residual renal function
will then lead to greater weight gains between dialysis sessions
requiring higher ultrafiltration rates and associated problems,
thereby creating a vicious cycle (Figure 1). The negative
impact on patient outcomes, including mortality, with
increasing ultrafiltration rates is well documented.70
What
happens if patients are dialyzed for shorter periods of time or
only 2 times per week, particularly if they have some residual
renal function and do not gain much weight between treat-
ments? Shorter hours as part of an incremental dialysis
regimen allowing for residual renal function when starting
dialysis has been shown to improve patient outcomes.71
Twice-weekly dialysis has also been shown to be safe in
those with significant residual renal function when
commencing HD and has the advantage of preserving the
residual function for longer.72
Customization of dialysis for older patients should also
consider frequency of dialysis.52
There is ample evidence to
suggest that more frequent HD (>3 times per week) can
improve left ventricular hypertrophy and blood pressure
control, as well as various patient-reported outcome mea-
sures, suggesting an improved patient perception of their
QoL.73–76
Importantly, the time to recovery after a dialysis
session decreases dramatically with more frequent HD.75
Depressive symptoms and sleep quality may improve, and
scores on the Short Form-36 often increase with more
frequent HD.74–76
How frail elderly patients will respond to
more frequent treatments is unclear and needs further
study52
; the patients included in these studies were younger,
and even in this population, there are concerns about loss of
residual renal function.77
In the short term, more frequent
dialysis may enable more intensive rehabilitation,78
but in the
long term would carry significant treatment burden and
intrusion into daily life, particularly when considering the
increased requirement of transport to and from a dialysis
center, unless the patient had support to carry out his or her
own dialysis at home.
Performing HD at home would enable greater individual
control over the dialysis prescription in terms of hours and
frequency and would avoid the need for transport to and
from dialysis centers. Many of the difficulties associated with
HD discussed previously present challenges, however, for
home HD, particularly the risk of intradialytic hypotension.
Realistically, patients would need family support or a paid
carer to be present throughout the dialysis. There are anec-
dotal and personal experience reports of older individuals
successfully having home HD, but there is remarkably little
published literature apart from 1 recently published series of
79 patients older than 65 years of age.79
Few of these patients,
however, were very old, as the median age was 68 years, and
the maximum was 88 years.
Increased
weight gain
Loss of
residual renal
function
Intradialytic
hypotension
Increased
ultrafiltration
requirements
Figure 1 | Ultrafiltration and loss of residual renal function: a
vicious cycle.
review EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient
298 Kidney International (2017) 91, 294–303

6. PD: advantages and disadvantages for the elderly
The advantages and disadvantages of PD are summarized in
Table 2. The principal advantage of PD is being able to have
treatment at home and thereby avoid the disruption and
discomfort of visits to hospital in all types of weather and
regardless of how the patient is feeling. A point that is often
not considered is the benefit of preservation of residual renal
function, allowing a relatively low dialysis prescription, which
minimizes treatment burden and intrusion into lifestyle. It is
well recognized that rate of decline in kidney function is lower
with increasing age. Calculation of PD clearance includes
residual renal function, thereby enabling an incremental in-
crease in the PD prescription as renal function declines; if
there is little decline, the dose of PD remains low. It is
therefore not uncommon to find older patients still using
only 2 or 3 continuous ambulatory peritoneal dialysis ex-
changes or not dialyzing every night for prolonged periods
after starting dialysis. There is, however, a lack of hard evi-
dence on which to base guidelines on how to deliver and
manage PD in the older population; the International Society
of Peritoneal Dialysis has therefore commissioned and
recently published a series of papers to give practical clinical
advice to support clinicians.80
PD eligibility for older patients depends on factors related
to the PD itself and on those more specifically related to aging
(Table 3). With planning and appropriate education, many of
these barriers can be surmounted. With appropriate educa-
tion, more than half of older patients would prefer to be on
PD.81
In this study of 134 older incident Canadian patients
with a median age of 73 years, 25% had visual problems, 20%
were considered immobile, and 17% had reduced hearing. In
units with assisted PD available, 80% patients were deemed
eligible for PD compared with 65% when assistance was not
available. In both groups, almost 60% of those eligible chose
PD. Oliver et al.82
have also shown how important social
support is for the eventual choice of PD; family support was
associated with an increase in PD eligibility from 63% to 80%
and PD choice from 40% to 57% in patients with barriers to
self-care. Successfully starting an older patient on PD therapy
is a multistep process that includes an assessment and
determination of eligibility, the offer of PD to an eligible
patient, the selection of PD as the modality of his/her choice,
and, ultimately, successful receipt of PD. This requires an
interdisciplinary team to adequately assess and educate older
patients about PD as a modality option. Barriers to PD often
emerge during this process but can often be overcome with
support by family members, home care workers, or staff in
long-term care facilities.83
Realistically, although some frail older patients are able to
perform their own PD, many cannot. In some instances,
family members will help, but usually, when this is not
possible, patients are placed on HD with all its difficulties,
and a few will opt for conservative care (i.e., no dialysis).
Patients incapable of self-care PD, however, could be sup-
ported through assisted PD for which trained staff or family
members provide daily dialysis assistance in either nursing
homes or patients’ homes. Assisted PD is available in many
European countries, in parts of Canada and Australia using
health care workers, and in many Middle Eastern, Asian, and
South American countries using extended family members,
or domestic help is often available. Assisted PD, however, is
not reimbursed in United States and thus is not readily
available unless provided by the patient’s family. Assisted PD
in Europe or Canada is usually delivered as assisted auto-
mated PD, as shown in Table 4; in France, however, assisted
continuous ambulatory peritoneal dialysis is predominantly
used. Experience in Denmark and France suggests that the
cost of assisted PD is equal to the cost of in-center HD.84
The
FEPOD study suggests that patients on assisted PD in the
United Kingdom have higher treatment satisfaction scores
than those on hospital HD.23
Although increasing availability
of assisted PD may enable more older patients to have dialysis
at home, as shown in Table 5, not all elderly patients are
suitable for assisted PD.
There is no evidence of PD-related complications being
more common in older patients. Although there has been
concern that peritonitis is more frequent in the elderly, this
has not been confirmed in most studies, even when patients
on assisted PD are included.85,86
The largest and most recent
study from the French PD Registry, which includes >3000
Table 3| Potential obstacles for PD in elderly patients
Potential obstacle Solution
PD related Previous lower
abdominal surgery
Consider surgically placed
catheter, but PD may be
contraindicated
(e.g., presence of colostomy;
previous pelvic radiotherapy)
Severe obesity Consider surgically placed
catheter and appropriate
placement of exit site
Housing; no storage space Can be contraindication, but
consider more frequent
smaller deliveries of supplies
Depression/anxiety May need psychological
assessment and
management, but consider
assisted PD
Age related Poor manual dexterity Consider assisted PD
Impaired physical activity
with difficulty in lifting
bags of fluid
Consider assisted PD
Impaired vision Consider assisted PD
Impaired hearing Use visual aids for training;
consider assisted PD
Cognitive dysfunction Consider assisted PD. Can be
contraindication if patient
gets agitated or at risk of
contaminating catheter or
exit site
General frailty Consider assisted PD
Social isolation Engaging community resources
and family for support;
consider assisted PD
Late presentation Consider acute start PD Æ
assisted PD
PD, peritoneal dialysis.
EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient review
Kidney International (2017) 91, 294–303 299

7. patients older than 75 years of age, also shows no difference in
infections from gram-positive or gram-negative organisms
between older and younger patients.85
Older patients, how-
ever, in whom peritonitis develops, have a high short-term
mortality and those with multiple comorbid conditions can
have an excessive risk of relapsing peritonitis episodes.86
Concerns about limiting the length of time on PD for older
patients should not be an issue for older patients. Even after 5
years on PD, the risk of encapsulating peritoneal sclerosis is
only w5%.87
For the older patient on PD, competing risk
considerations would suggest that death is a greater risk than
the development of encapsulating peritoneal sclerosis.
Transferring to HD at some arbitrary time period would have
a major impact on lifestyle and QoL, could well be deleterious
in terms of progression of cognitive dysfunction and physical
function, and actually increase the risk of the development of
the full clinical syndrome of encapsulating peritoneal scle-
rosis, which usually only develops when PD is discontinued.87
Challenges for the health care system
The models of care for patients on dialysis were devised at a
time when the majority were young and most were eligible for
transplantation. Dialysis populations have changed dramati-
cally with the aging of the general population. None of these
studies shows major differences between patient outcomes on
PD and HD for older patients. Whatever the dialysis modality,
they have a high burden of aging-related problems, a high
mortality rate, and a high rate of the frailty syndrome
developing, requiring social support within a few months of
starting dialysis, whatever the modality.88
Given this experi-
ence and observations that dialysis may not extend life in the
very old, the multiply comorbid, or those with poor physical
function,42–44
it is not surprising that a high percentage of the
very old select conservative care (no dialysis but active sup-
portive care) in health care cultures where this option is
actively discussed.29,89
These clinical experiences resulted in
the recent publication of a paper introducing the term dialysis
as final destination.6
In this paper, Vandercastle and Tamura
suggested that for patients with a limited prognosis (as for the
old and frail), focusing on the delivery of dialysis and its
associated standards could impose a treatment burden that
would not translate into a proportional improvement in
quality or QoL and that therefore management should be
patient centered with adaptation of dialysis to patient
need backed up by appropriate palliative support. This
approach entails a detailed discussion with patients and their
families about the burdens and perceived benefits of dialysis;
underdialysis may exacerbate symptoms and may not be
desired by all.
If, as discussed, dialysis may not extend life expectancy for
the old and frail individual, what are the aims of starting such
an interventional treatment? All dialysis modalities will have a
major effect on the day-to-day life of a patient and his or her
family, are associated with numerous major and minor
complications, and come with significant economic costs to
society and the patient (more or less depending on the health
care system). Delivery of dialysis, therefore, for this group of
patients should focus on improving symptoms, minimizing
complications, and maintaining, or optimistically improving,
physical, mental, and social activities that are important for
the patient (Table 6).
We actually do not know how much dialysis an older frail
patient needs or even when dialysis should be commenced.
It is naïve to think that a frail older patient with low muscle
mass, low food intake, low physical activity, and therefore
low energy expenditure requires the same dialysis dose as a
younger and more physically active patient. We do know
that with increasing age, residual renal function declines
more slowly in patients with chronic kidney disease,34
and
those with conservative care programs will be familiar with
patients who remain remarkably stable despite glomerular
filtration rates as low as 5 ml/min (E. Brown, personal
observation). An individualized approach to dialysis
including appreciation of residual renal function may enable
a less intensive and therefore intrusive dialysis regimen.
Although this is a standard approach in PD, this could be a
challenge for many HD units, as residual renal function is
not routinely measured and processes of dialysis delivery are
Table 4| Models of delivering assisted PD
Canada and Europe (not including United Kingdom and France)
Mostly APD
Community nurses visit twice a day
Morning visit to disconnect patient from cycler machine, remove used
bags, and set up machine with new bags for the evening
Shorter evening visit to connect patient to cycler machine
Main disadvantage is cost of using nurses and providing 2 visits/day
France
Mostly CAPD using nondisconnect systems
Private community nurse visits 3–4 times a day
Nurse phones patient before visit to start draining thereby reducing
length of visit
United Kingdom
Mostly APD; CAPD if needed
Daily visit from a health care assistant (individual with short basic
training in health care)
Salary of health care assistant is less than a nurse
One visit a day: assistant takes used bags off cycler machine and sets up
machine with new bags; also checks blood pressure and weight of
patient and can perform exit site dressings
Extra visits for connection/disconnection or CAPD as clinically indicated
Patient (with or without family support) does his/her own connection to
and disconnection from the cycler machine.
APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal
dialysis.
Table 5| Relative contraindications to assisted APD
Restlessness at night so unable to stay on machine
Living alone and unable to be trained for eventuality of machine
alarming overnight (if necessary, response can be just to switch off
machine)
Unable to be trained to disconnect from machine in emergency and no
family member/carer to help
Accommodation too small for cycling machine and fluid supplies
Patient proves to be unreliable, so frequently not at home when as-
sistant calls
APD, automated peritoneal dialysis.
review EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient
300 Kidney International (2017) 91, 294–303

8. often focused on achieving designated targets and enabling
patient throughput.
CONCLUSIONS
There is no one correct way to deliver either HD or PD to the
frail older patient. Both should be prescribed within a
framework of total care, focusing on the needs of that person
(Table 6). Perhaps maintaining residual renal function should
be one of the goals for both modalities. For HD, this would
result in less dependence on high ultrafiltration rates and
consequent intradialytic hypotension. For PD, the advantages
are fewer exchanges and days off dialysis.
Given what we know and what we do not know about the
effectiveness of HD and PD on outcomes for elderly patients
with end-stage kidney disease, it is particularly important to
examine how patients and their physicians make decisions
about whether to initiate renal replacement treatment, and if
chosen, which dialysis modality is best for that patient. Un-
derstanding each individual’s goals of care in the context of
their life experience90
is particularly important in the elderly,
when overall life expectancy is relatively short, and life
experience or QoL may be the priority. Although population-
based predictive models can help patients and physicians
understand which dialysis modality may enhance survival or
might exacerbate a coexisting condition, each patient must
assess how these predictions affect their own personal prior-
ities of care. For example, a frail elderly woman who loves to
spend a few hours reading each day may have a different view
of post-HD fatigue than an elderly man who loves his
afternoon naps. A man with intractable low cardiac output
congestive heart failure may return to more family life
without dyspnea with home nocturnal HD even though this
treatment likely does not give him a survival advantage.91
Collaborative decision making is particularly important in
the elderly, in which each patient’s treatment goal priorities
are examined and physicians consider these priorities and
choices prominently as they make recommendations for best-
evidence care, and in which physicians guide patients and
their families in making decisions.92
Just as individual patients and their physicians collabo-
ratively choose best patient-centered treatment, our societal
commitment to ensure best-quality care must also recognize
the importance of patient priorities and choice. Clinical
performance measures are used in many countries to assess
the quality of care delivered to dialysis patients. Most of
these measures are designed to assess outcomes of care such
as mortality, hospitalization, and infection rates, and process
metrics such as the efficiency of solute removal (Kt/V urea),
vascular access type or frequency, or hypercalcemia.93
Some
“patient experience” measures such as the Consumer
Assessment of Healthcare Providers and Systems have also
been used to assess the quality of care. Is 1 set of clinical
performance measures appropriate for all dialysis patients?
Just as each patient and physician need to tailor health care
choices, our assessment of health care quality should like-
wise be individualized.94
We have recommended that a
balanced scorecard of quality performance should include 3
elements: population-based best clinical practice, patient
perceptions of his or her care, and individually crafted
patient goals of care.
In conclusion, the answer is “no” to the question “PD or
HD for the frail elderly patient, the choice of 2 evils?” Elderly
patients often have complex medical conditions and wide-
ranging priorities for their care. With multifaceted assess-
ments of care, physicians should be able to give these
individuals the ability to select and continue to make the best
decisions for their care. We have discussed how both PD and
HD can be modulated to optimize individual patient expe-
rience. The challenge is how this approach can be incorpo-
rated into current health care structures.
DISCLOSURE
EAB has received speaker fees and research funding from Baxter
Healthcare. All the other authors declared no competing interests.
REFERENCES
1. William Osler. Available at: http://www.osler.co.uk/williamosler/ Accessed
May 2, 2016.
2. Gilg J, Caskey F, Fogarty D. UK Renal Registry 18th
Annual Report:
Chapter 1 UK Renal Replacement Therapy Incidence in 2014: National
and Centre-specific Analyses. Available at: https://www.renalreg.org/wp-
content/uploads/2015/12/Chapter-01_v3.pdf. Accessed March 28, 2016.
3. U.S. Renal Data System, USRDS 2015 Annual Data Report: Volume 2 – End-
stage Renal Disease (ESRD) in the United States. Chapter 1. Available at:
http://www.usrds.org/2015/view/v2_01.aspx. Accessed March 28, 2016.
4. Rapport annuel 2013 du Réseau Epidémiologie et Information en
Néphrologie (REIN). Available at: http://www.agence-biomedecine.fr/
IMG/pdf/rapport_rein2013.pdf Accessed April 4, 2016.
Table 6| Impact of frailty on patient management
Frailty aspects Clinical considerations Health care challenges
Cognitive
impairment
Degree of impairment and
appropriateness of
dialysis
Strategies to limit the
impact of dialysis on
cognitive impairment
Incorporation of cognitive
assessment into routine
nephrologic care
Time for complex discussions
and advance care planning
Adjustment to dialysis
Functional
impairment
Potential impact of dialysis
on functional decline
Dependence and optimal
dialysis modality
Exercise as a preventive
strategy
Falls and fracture risk
Transport requirements
Liaison with geriatric teams
for assessment, falls clinics,
and community support
Involvement of rehabilitation
teams
Routine use of exercise
physiotherapists
Cost of transport
Protein energy
wasting
Prognostic marker for
outcomes on dialysis
Ensuring adequate
nutritional support
Regular dietetic review and
access to nutritional
supplements
Support in community for
shopping, preparing food
Multimorbidity Dialysis tolerability and
time to dialysis recovery
Polypharmacy and risk of
adverse reactions
Adjustment of HD to reduce
time to recover
Increased use of PD
Involvement of pharmacists
to review medications
Resetting of goals to restrict
medications to symptom
control
HD, hemodialysis; PD, peritoneal dialysis.
EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient review
Kidney International (2017) 91, 294–303 301

9. 5. Kauf F, Aaronson PS. ESRD as a window into America’s cost crisis in
health care. J Am Soc Nephrol. 2009;10:2093–2097.
6. Vandecasteele SJ, Tamura MK. A patient-centered vision of care for ESRD:
dialysis as a bridging treatment or as a final destination? J Am Soc
Nephrol. 2014;25:1647–1641.
7. Churchill DN, Jassal SV. Dialysis: destination or journey? J Am Soc Nephrol.
2014;25:1609–1611.
8. Roderick P, Jones C, Drey N, et al. Late referral for end-stage renal
disease: a region-wide survey in the south west of England. Nephrol Dial
Transplant. 2002;17:1252–1259.
9. Kurella M, Chertow GM, Fried LF, et al. Chronic kidney disease and
cognitive impairment in the elderly: the health, aging, and body
composition study. J Am Soc Nephrol. 2005;16:2127–2133.
10. Johansen KL, Chertow GM, Jin C, Kutner NG. Significance of frailty among
dialysis patients. J Am Soc Nephrol. 2007;18:2960–2967.
11. Roshanravan B, Khatri M, Robinson-Cohen C, et al. A prospective study of
frailty in nephrology-referred patients with CKD. Am J Kidney Dis. 2012;
60:912–921.
12. Chiu E, Markowitz SN, Cook WL, Jassal SV. Visual impairment in elderly
patients receiving long-term hemodialysis. Am J Kidney Dis. 2008;52:
1131–1138.
13. Cook WL, Jassal SV. Functional dependencies among the elderly on
hemodialysis. Kidney Int. 2008;73:1289–1295.
14. The Information Centre for Health and Social Care. Survey of Carers in
households in England 2009/10. Available at: http://content.digital.
nhs.uk/catalogue/PUB02200/surv-care-hous-eng-2009-2010-rep1.pdf.
Accessed October 5, 2016.
15. MacNeill SJ, Casula A, Shaw C, Castledine C. UK Renal Registry 18th
Annual Report: Chapter 2 UK Renal Replacement Therapy Prevalence in
2014: National and Centre-specific Analyses. Available at: https://www.
renalreg.org/wp-content/uploads/2015/12/Chapter-02_v3.pdf. Accessed
March 28, 2016.
16. van de Luijtgaarden MWM, Noordzij M, Stel VS, et al. Effects of comorbid
and demographic factors on dialysis modality choice and related patient
survival in Europe. Nephrol Dial Transplant. 2011;26:2940–2947.
17. Clegg A, Young J, Iliff S, et al. Frailty in elderly people. Lancet. 2013;381:
752–762.
18. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of
fitness and frailty in elderly people. CMAJ. 2005;173:489–495.
19. McAdams-DeMarco MA, Tan J, Salter ML, et al. Frailty and cognitive
function in incident hemodialysis patients. Clin J Am Soc Nephrol. 2015;
10:2181–2189.
20. Alfaadhel TA, Soroka SD, Kiberd BA, et al. Frailty and mortality in dialysis:
evaluation of a clinical frailty scale. Clin J Am Soc Nephrol. 2015;10:
832–840.
21. Johansen KL, Dalrymple LS, Glidden D, et al. Association of performance-
based and self-reported function-based definitions of frailty with
mortality among patients receiving hemodialysis. Clin J Am Soc Nephrol.
2016;11:626–632.
22. Pugh J, Aggett J, Goodland A, et al. Frailty and comorbidity are
independent predictors of outcome in patients referred for pre-dialysis
education. Clin Kidney J. 2016;9:324–329.
23. Iyasere OU, Brown EA, Johansson L, et al. Quality of life and physical
function in older patients on dialysis: a comparison of assisted
peritoneal dialysis with hemodialysis. Clin J Am Soc Nephrol. 2016;11:
423–430.
24. Kraai IH, Vermeulen KM, Luttiki MLA, et al. Preferences of heart failure
patients in daily clinical practice: quality of life or longevity? Eur J Heart
Failure. 2013;15:1113–1121.
25. Higginson IJ, Gomes B, Calanzani N, et al. Priorities for treatment,
care and information if faced with serious illness: a comparative
population-based survey in seven European countries. Palliat Med.
2014;28:101–110.
26. Konicki HM, Swidler MA. Decision making in elderly patients with
advanced kidney disease. Clin Geriatr Med. 2013;29:641–655.
27. Stiggelbout AM, Van der Weijden t, De Wit MPT, et al. Shared decision
making: really putting patients at the centre of healthcare. BMJ.
2012;344:e256.
28. Muthalagappan S, Johansson L, Kong WM, Brown EA. Dialysis or
conservative care for frail older patients: ethics of shared decision-
making. Nephrol Dial Transplant. 2013;28:2717–2722.
29. Tonkin-Crine S, Okamoto I, Laydon GM, et al. Understanding by older
patients of dialysis and conservative management for chronic kidney
failure. Am J Kidney Dis. 2015;65:443–450.
30. Joly D, Anglicheau D, Alberti C, et al. Octogenarians reaching end-stage
renal disease: cohort study of decision-making and clinical outcomes.
J Am Soc Nephrol. 2003;14:1012–1021.
31. Couchoud C, Labeeuw M, Moranne O, et al., French Renal Epidemiology
and Information Network (REIN) registry. A clinical score to predict
6-month prognosis in elderly patients starting dialysis for end-stage
renal disease. Nephrol Dial Transplant. 2009;24:1553–1561.
32. Floege J, Gillespie I, Kronenberg F, et al. Development and validation of a
predictive mortality risk score from a European haemodialysis cohort.
Kidney Int. 2015;87:996–1008.
33. Couchoud CG, Beuscart JBR, Aldigier JC, et al. Development of a risk
stratification algorithm to improve patient-centered care and decision
making for incident elderly patients with end-stage renal disease. Kidney
Int. 2015;88:1178–1186.
34. O’Hare AM, Choi AI, Bertenthal D, et al. Age affects outcomes in chronic
kidney disease. J Am Soc Nephrol. 2007;18:2758–2765.
35. Harris SAC, Lamping DL, Brown EA, Constantinovici N, for the NTDS
Group. Dialysis modality and elderly people: Effect on clinical outcomes
and quality of life. Perit Dial Int. 2002;22:463–470.
36. Lamping DL, Constantinovici N, Roderick P, et al. Clinical outcomes,
quality of life, and costs in the North Thames Dialysis Study of elderly
people on dialysis: a prospective cohort study. Lancet. 2000;356:
1543–1550.
37. NICE (National Institute for Health and Care Excellence). Chronic kidney
disease (stage 5): peritoneal dialysis. Clinical guideline. Available at:
https://www.nice.org.uk/guidance/cg125/resources/chronic-kidney-
disease-stage-5-peritoneal-dialysis-35109451582405. Accessed April 2,
2016.
38. Han SS, Park JY, Kang S, et al. Dialysis modality and mortality in the
elderly: a meta-analysis. Clin J Am Soc Nephrol. 2015;10:983–993.
39. Iyasere O, Brown EA. Mortality in the elderly on dialysis: is this the right
debate? Clin J Am Soc Nephrol. 2015;10:920–922.
40. Castrale C, Evans D, Verger C, et al. Peritoneal dialysis in elderly patients:
report from the French Peritoneal Dialysis Registry (RDPLF). Nephrol Dial
Transplant. 2010;25:255–262.
41. Lee MB, Bargman JM. Survival by dialysis modality–who cares? Clin J Am
Soc Nephrol. 2016;11:1083–1087.
42. Chandna SM, Da Silva-Gane M, Marshall C, et al. Survival of elderly
patients with stage 5 CKD: comparison of conservative management and
renal replacement therapy. Nephrol Dial Transplant. 2011;26:1608–1614.
43. Hussain JA, Mooney A, Russon L. Comparison of survival analysis and
palliative care involvement in patients aged over 70 years choosing
conservative management or renal replacement therapy in advanced
chronic kidney disease. Palliat Med. 2013;27:829–839.
44. Verberne WR, Geers ABMT, Jellema WT, et al. Comparative survival among
older adults with advanced kidney disease managed conservatively
versus with dialysis. Clin J Am Soc Nephrol. 2016;11:633–640.
45. Morton R. Factors influencing patient choice of dialysis versus conservative
care to treat end-stage kidney disease. CMAJ. 2012;184:E277–E283.
46. WachtermanMW,MarcantonioER,DavisRB, et al. Relationship betweenthe
prognostic expectations of seriously ill patients undergoing hemodialysis
and their nephrologists. JAMA Intern Med. 2013;173:1206–1214.
47. Brown EA, Johansson L, Farrington K, et al. Broadening Options for Long-
term Dialysis for the Elderly (BOLDE): differences in quality of life on
peritoneal dialysis compared to haemodialysis for older patients. Nephrol
Dial Transplant. 2010;25:3755–3763.
48. Wolfgram D, Szabo A, Murray AM, Whittle J. Risk of dementia in
peritoneal dialysis patients compared with haemodialysis patients. Perit
Dial Int. 2015;35:189–198.
49. Wang IK, Cheng YK, Lin CL, et al. Comparison of subdural hematoma risk
between haemodialysis and peritoneal dialysis patients with ESRD. Clin J
Am Soc Nephrol. 2015;10:994–1001.
50. Wang HH, Hung SY, Sung JM, et al. Risk of stroke in long-term dialysis
patients compared with the general population. Am J Kidney Dis. 2014;
63:604–611.
51. Farragher J, Rajan T, Chiu E, et al. Equivalent fall risk in elderly patients on
hemodialysis and peritoneal dialysis. Perit Dial Int. 2016;36:67–70.
52. Chazot C, Farrington K, Nistor I, et al. Pro and con arguments in using
alternative dialysis regimens in the frail and elderly patients. Int Urol
Nephrol. 2015;47:1809–1816.
53. Thamer M, Kaufman JS, Zhang Y, et al. Predicting early death among
elderly dialysis patients: development and validation of a risk score to
assist shared decision making for dialysis initiation. Am J Kidney Dis.
2015;66:1024–1032.
review EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient
302 Kidney International (2017) 91, 294–303

10. 54. Ghaffar U, Easom AK. A quality improvement project: Strategies to
reduce intradialytic hypotension in hemodialysis patients. Nephrol News
Issues. 2015;29:30–34.
55. Sands JJ, Usvyat LA, Sullivan T, et al. Intradialytic hypotension: frequency,
sources of variation and correlation with clinical outcome. Hemodial Int.
2014;18:415–422.
56. Burton JO, Jefferies HJ, Selby NM, McIntyre CW. Hemodialysis-induced
repetitive myocardial injury results in global and segmental
reduction in systolic cardiac function. Clin J Am Soc Nephrol. 2009;4:
1925–1931.
57. Burton JO, Jefferies HJ, Selby NM, McIntyre CW. Hemodialysis-induced
cardiac injury: determinants and associated outcomes. Clin J Am Soc
Nephrol. 2009;4:914–920.
58. Chen HJ, Qi R, Kong X, et al. The impact of hemodialysis on cognitive
dysfunction in patients with end-stage renal disease: a resting-state
functional MRI study. Metab Brain Dis. 2015;30:1247–1256.
59. Prohovnik I, Post J, Uribarri J, et al. Cerebrovascular effects of
hemodialysis in chronic kidney disease. J Cereb Blood Flow Metab.
2007;27:1861–1869.
60. McIntyre CW, Harrison LE, Eldehni MT, et al. Circulating endotoxemia: a
novel factor in systemic inflammation and cardiovascular disease in
chronic kidney disease. Clin J Am Soc Nephrol. 2011;6:133–141.
61. Rayner HC, Zepel L, Fuller DS, et al. Recovery time, quality of life, and
mortality in hemodialysis patients: the Dialysis Outcomes and Practice
Patterns Study (DOPPS). Am J Kidney Dis. 2014;64:86–94.
62. Lindsay RM, Heidenheim PA, Nesrallah G, et al., Daily Hemodialysis Study
Group London Health Sciences Centre. Minutes to recovery after a
hemodialysis session: a simple health-related quality of life question that
is reliable, valid, and sensitive to change. Clin J Am Soc Nephrol. 2006;1:
952–959.
63. Dimkovic N, Oreopoulos DG. Management of elderly patients with end
stage kidney disease. Semin Nephrol. 2009;29:643–649.
64. Lazarides MK, Georgiadis GS, Antoniou GA, Staramos DN. A meta-
analysis of dialysis access outcome in elderly patients. J Vasc Surg.
2007;45:420–426.
65. Drew DA, Lok CE, Cohen JT, et al. Vascular access choice in incident
haemodialysis patients: a decision analysis. J Am Soc Nephrol. 2015;26:
183–191.
66. Lomonte C, Forneris G, Gallieni M, et al. The vascular access in the
elderly: a position statement of the Vascular Access Working Group of
the Italian Society of Nephrology. J Nephrol. 2016;29:175–184.
67. Medicare.gov. Dialysis information for people with End-Stage Renal
Disease (ESRD). Available at: https://www.medicare.gov/people-like-me/
esrd/dialysis-information.html. Accessed April 11, 2016.
68. National Kidney Care Audit. Patient Transport Survey 2010. Available at:
http://www.hscic.gov.uk/catalogue/PUB02700/nati-kidn-care-2010-pati-
tran-surv-upda-rep.pdf. Accessed April 11, 2016.
69. National Kidney Foundation. KDOQI clinical practice guideline for
hemodialysis adequacy: 2015 update. Am J Kidney Dis. 2015;66:884–930.
70. Flythe JE, Kimmel SE, Brunelli SM. Rapid fluid removal during dialysis
is associated with cardiovascular morbidity and mortality. Kidney Int.
2011;79:250–257.
71. Vilar E, Wellsted D, Chandna SM, et al. Residual renal function improves
outcome in incremental haemodialysis despite reduced dialysis dose.
Nephrol Dial Transplant. 2009;24:2502–2510.
72. Obi Y, Steja B, Rhee CM, et al. Incremental hemodialysis, residual kidney
function and mortality risk in incident dialysis patients: a cohort study.
Am J Kidney Dis. 2016;68:256–265.
73. FHN Trial Group, Chertow GM, Levin NW, Beck GJ, et al. In-center
hemodialysis six times per week versus three times per week. N Engl J
Med. 2010;363:2287–2300.
74. Finkelstein FO, Schiller B, Daoui R, et al. At-home short daily hemodialysis
improves the long-term health-related quality of life. Kidney Int. 2012;82:
561–569.
75. Jaber BL, Schiller B, Burkart JM, et al., FREEDOM Study Group. Impact of
short daily hemodialysis on restless legs symptoms and sleep
disturbances. Clin J Am Soc Nephrol. 2011;6:1049–1056.
76. Jaber BL, Lee Y, Collins AJ, et al. Effect of daily hemodialysis on depressive
symptoms and postdialysis recovery time: interim report from the
FREEDOM (Following Rehabilitation, Economics and Everyday-Dialysis
Outcome Measurements) Study. Am J Kidney Dis. 2010;56:531–539.
77. Daugirdas JT, Greene T, Rocco MV, et al., FHN Trial Group. Effect of
frequent hemodialysis on residual kidney function. Kidney Int. 2013;83:
949–958.
78. Li M, Porter E, Lam R, Jassal SV. Quality improvement through the
introduction of interdisciplinary geriatric hemodialysis rehabilitation
care. Am J Kidney Dis. 2007;50:90–97.
79. Cornelis T, Tennankore KK, Goffin E, et al. An international feasibility
study of home haemodialysis in older patients. Nephrol Dial Transplant.
2014;29:2327–2333.
80. Brown EA, Bargman JM, Li PK. Managing older patients on peritoneal
dialysis. Perit Dial Int. 2015;35:609–611.
81. Oliver MJ, Quinn RR, Richardson EP, et al. Home care assistance and the
utilization of peritoneal dialysis. Kidney Int. 2007;71:673–678.
82. Oliver MJ, Garg AX, Blake PG, et al. Impact of contraindications, barriers
to self-care and support on incident peritoneal dialysis utilization.
Nephrol Dial Transplant. 2010;25:2737–2744.
83. Oliver MJ, Quinn RR. Selecting peritoneal dialysis in the older dialysis
population. Perit Dial Int. 2015;35:618–621.
84. Béchade C, Lobbedez T, Ivarsen P, Povlsen JV. Assisted peritoneal dialysis
for older people with end-stage renal disease: the French and Danish
experience. Perit Dial Int. 2015;35:663–666.
85. Szeto CC. Peritoneal dialysis-related infection in the older population.
Perit Dial Int. 2015;35:659–662.
86. Duquennoy S, Bechade C, Verger C, et al. Perit Dial Int. 2016;36:291–296.
87. Goodlad CJ, Brown EA. Encapsulating peritoneal sclerosis–what have we
learnt? Semin Nephrol. 2011;31:183–198.
88. Jassal SV, Chiu E, Hladunewich M. Loss of independence in patients starting
dialysis at 80 years of age or older. N Engl J Med. 2009;361:1612–1613.
89. Morton RL, Turner RM, Howard K, et al. Patients who plan for
conservative care rather than dialysis: a national observational study in
Australia. Am J Kidney Dis. 2012;59:419–427.
90. Finkelstein FO. Performance measures in dialysis facilities: what is the
goal? Clin J Am Soc Nephrol. 2015;10:156–158.
91. Rocco MV, Daugirdas JT, Greene T, et al., FHN Trial Group. Long-term
effects of frequent nocturnal hemodialysis on mortality: the Frequent
Hemodialysis Network (FHN) Nocturnal Trial. Am J Kidney Dis. 2015;66:
459–468.
92. Barry MJ, Edgman-Levitan S. Shared decision making – pinnacle of
patient-centered care. N Engl J Med. 2012;366:780–781.
93. Centers for Medicare Medicaid Services: ESRD QIP Payment Year 2018
Program Details. Available at: https://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-Instruments/ESRDQIP/Downloads/PY-2
018-Program-Details.pdf. Accessed June 4, 2016.
94. Kliger AS. Quality measures for dialysis: time for a balanced scorecard.
Clin J Am Soc Nephrol. 2016;11:363–368.
EA Brown et al.: Peritoneal or hemodialysis for the frail elderly patient review
Kidney International (2017) 91, 294–303 303