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Renal replacement therapy in the elderly.

Only recently have increasing facilities and the development of continuous ambulatory peritoneal dialysis enabled us to extend regular dialysis to elderly patients. In this issue, Williams and Antao [1] show that renal replacement therapy is a perfectly feasible procedure for elderly people. However they also point out that, in spite of the rising number of new patients admitted to dialysis, renal replacement therapy in Britain is still denied to many older patients. A similar impression is given by the data of the European Renal Association [2]. In 1985 fewer than 20 per cent of European patients were older than 65 at the start of dialysis, the corresponding figures being 59 per cent in the experience of Williams and Antao. Even in the United States, the older the patient the less his chance to receive dialysis [3]. Prediction of high mortality and of poor quality of life are probably the main factors responsible for persistent discrimination against the elderly. As expected, mortality rises with age. The European Renal Association for 1983 reported a two-year survival rate of 56 per cent for haemodialysis patients older than 70 versus 80 per cent for those aged 45-54 [4]. These data, however, should be read in terms of life expectancy for a certain range of age, rather than in terms of crude survival rate. Chester et al. [5] reported that, since the life expectancy for the 75-year cohort of the normal population is 9.5 years, the mean survival rate of 22 months they observed in their elderly dialysis patients would correspond to 16 per cent of their life expectancy if healthy. This compared favourably with the life expectancy of 10 per cent observed in their dialysis patients aged 40. Thus neither the referral nor the acceptance of older patients for dialysis should be limited by fear of a poor prognosis. The problem of rehabilitation is more complex. Williams and Antao report that most of their patients 75 or more led reasonably independent lives. In the European Registry many older patients receiving dialysis ranked themselves as having a high quality of life [6]. Unfortunately, however, dialysis is not always successful for the elderly. Some patients may become excessively dependent or may refuse to adhere to schedules. Others may develop progressive dementia, severe heart failure or lower limb gangrene, so that it is not uncommon for older patients or their relatives to ask for dialysis to be interrupted [7, 8]. Can we identify which patient will adapt to dialysis? The distinction between fit and frail elderly is not easy in a normal population [9] and it becomes extremely difficult for older uraemics. Patients who were active and lively at the start of dialysis may develop apathy, dementia or cachexia. Others, who had been judged unfit for dialysis, may adapt surprisingly well to the limitations imposed by treatment [4, 5]. Even comorbidity is often insufficient to predict how a patient will react [8]. It seems, therefore, unethical to offer a vital treatment solely on the basis of chronological age. A trial of dialysis should be offered to most older patients.