Dialysis Reduction in Older Adults with Terminal Kidney Insufficiency

Introduction to Dialysis Reduction

The American Journal of Kidney Diseases recommends that the decision to start or reduce dialysis intensity in older patients with terminal kidney insufficiency should be based on an individualized approach that integrates life expectancy, comorbidity, functional status, and patient preferences, with conservative management without dialysis being a reasonable alternative for patients with limited life expectancy or severe comorbidity 1

The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recognize that not all patients require standard three-times-a-week dialysis: twice-a-week dialysis can be considered for patients with residual kidney function (Kr) > 2 mL/min/1.73 m², but is not suitable for patients with Kr < 2 mL/min/1.73 m² 2
For patients with substantial residual kidney function, the minimum dialysis dose can be reduced to 60% of the minimum target for patients without residual kidney function, depending on dialysis frequency 2
Residual kidney function should be monitored at least quarterly when dialysis dose is reduced 2

The minimum treatment time of 3 hours per session remains recommended for patients with low residual kidney function who dialyze three times a week, even in older adults 3
Longer dialysis sessions (4-5 hours) are associated with better blood pressure control and less hemodynamic instability, particularly in patients older than 65 years 3

The Centers for Medicare and Medicaid Services (CMS) policy creates financial incentives for dialysis with a "one-size-fits-all" approach and discourages medical management without dialysis 1
Access to hospice is severely limited for dialysis patients at the end of life 1
Payment for concurrent hospice and dialysis should be implemented 1
Funding for demonstration projects that explore medical management without dialysis as a treatment option is needed 1
A separate set of ESRD Quality Incentive Program metrics for seriously ill patients who dialyze should be developed, including documented shared decision-making, advance care planning discussions, and referrals to hospice 1

Avoid automatically applying standard dialysis guidelines to very old patients - strict application of guidelines may be inappropriate for certain patients with limited life expectancy 4
Monitor residual kidney function closely when dialysis intensity is reduced, especially after events that can acutely decrease kidney function 2
Recognize that current evidence does not allow a prescriptive approach for the timing of dialysis initiation - this decision remains within the domain of the "art" of medicine and requires individual assessment 4