Lecture Code : DS01-S3
Session Name : Dialysis Specialist Physician Course 1
Session Topic : Dialysis Specialist Physician Course 1
Date & Time, Place : June 14 (Sun) / 08:30-10:30 / Room 3 (GBR 103), 1F
Very Old ESRD Patients: Hemodialysis Versus Palliative
Yohan Park
Konyang University Hospital, Republic of Korea
The proportion of elderly patients initiating kidney replacement therapy (KRT) is rapidly increasing, particularly in Korea, where aging is progressing at an unprecedented rate. Currently, elderly patients account for a substantial proportion of incident dialysis populations, approaching nearly 60%. However, elderly patients are a highly heterogeneous group, and clinical outcomes vary significantly across age strata. In particular, the “very old” or “oldest old,” typically defined as those aged ≥85 years, represent a distinct population requiring individualized and tailored treatment approaches.
In this population, the benefits of hemodialysis are often uncertain. While dialysis can be technically feasible, many very old patients have multiple comorbidities, frailty, malnutrition, and functional decline, which are strongly associated with poor outcomes. Notably, early mortality—defined as death within 6 months of dialysis initiation—is substantially higher in very old patients, raising concerns about the net benefit of initiating dialysis in high-risk patients.
To support decision-making, prognostic tools such as the REIN score have been developed to estimate early mortality risk. Patients identified as high-risk may derive limited survival benefit from dialysis, and in such cases, conservative kidney management (CKM) should be actively considered.
CKM is a patient-centered, palliative approach that prioritizes quality of life over life-prolonging interventions. Rather than focusing on dialysis, CKM emphasizes symptom control and supportive care. In this lecture, we will focus on key clinical domains of CKM, particularly metabolic and volume management, including the role of sodium bicarbonate, dietary protein restriction, phosphate control, PTH-lowering therapy, and sodium and fluid management, while briefly addressing symptom control.
In very old patients with end stage kidney disease (ESKD), treatment decisions should be individualized through shared decision-making, with CKM presented as a valid and appropriate alternative to dialysis in selected patients.
Keywords: Conserative kidney management, Elderly, Hemodialysis, Shared decision making