Peritoneal dialysis versus haemodialysis in the very old

Age itself is not a contraindication to dialysis or transplantation. Older patients can be treated effectively with either haemodialysis (HD) or peritoneal dialysis (PD), and most studies confirm that survival on PD and HD is similar in the elderly. Replacement therapy is started when GFR falls below 10 mL/min.

Practical problems with HD in the very old: difficulty creating an arteriovenous fistula, permanent catheter or graft infection, gastrointestinal bleeding, intradialytic hypotension, headache, vomiting, cramps, angina, arrhythmias and cardiovascular instability.

Practical problems with PD in the very old: dialysate leakage, formation of hernias, backache, difficulty in learning the technique, social isolation, family burn-out, and worsening of peripheral vascular disease or malnutrition.

When PD is the better choice. PD is preferable in patients with residual diuresis, severe hypotension, complicated or short-lived vascular access, intradialytic arrhythmias, angina, or cardiovascular instability. Automated forms — CCPD and nightly PD — are alternatives for the more vulnerable elderly, including nursing-home residents.

Nutrition and bone. Malnutrition is frequent: provide >1 g/kg/day protein on HD and >1.2 g/kg/day on PD. Older dialysis patients develop more severe bone disease than the young because of osteopenia, unbalanced diet, reduced physical activity and lack of sun exposure.

Prognosis and predictors of poor outcome. Poor nutritional status, dementia, gait disorders, impaired ADLs and IADLs, and late referral to nephrology. Median survival on HD is 15.6 months at 80–84 years and 11.6 months at 85–89 years. Leading causes of death in the oldest dialysis patients: elective withdrawal 38%, cardiovascular events 24%, infection 22%.

Shared decision-making with conservative kidney management as a genuine third option. Current international practice frames the choice not as "HD versus PD" but as HD versus PD versus conservative kidney management (CKM), with modality decided by frailty, cognition, functional status and what matters to the patient rather than by age or eGFR alone — CKM may deliver comparable survival with better quality of life in the frail, dependent very old. In India, assisted / home-based PD is being expanded under the national dialysis programme and AB-PMJAY, because it avoids thrice-weekly travel, is haemodynamically gentler, and suits an older population living with family caregivers.