Peritoneal Dialysis International, Vol. 35, pp. 609–611 0896-8608/15 $3.00 + .

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FROM THE EDITORS

MANAGING OLDER PATIENTS ON PERITONEAL DIALYSIS

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“You are old, Father William,” the young man said, papers are designed to be clinically practical and have a list
And your hair has become very white; of key points. These are summarized in the following table:
And yet you incessantly stand on your head
Do you think, at your age, it is right?”
Topic Key points
—Lewis Carroll
Peritoneal dialysis • Catheter outcomes (function, exit-site

I t is hardly a surprise that global ageing is being mirrored

in the age of people requiring dialysis. Furthermore, the
age-related incidence of end-stage kidney disease (ESRD) is
access infection) are identical to those in
younger patients
• This is in contrast to access for HD
highest in the oldest age groups — and the majority of these where fistula and graft failure is higher
patients are not eligible for transplantation. The epidemiology in older patients
of the dialysis population has therefore markedly changed in Patient and technique • There have been greater improvements
the 50 years since maintenance dialysis was introduced in the survival in mortality for patients treated with
1960s. Guidelines on management of patients with ESRD tend PD than for those treated with HD in
to focus on dialysis management with easy-to-measure targets many different parts of the world
such as blood pressure, hemoglobin, Kt/V urea and phos- • The preponderance of evidence from
phate levels. For older patients, quality of life is particularly contemporary studies shows that in
important and, for many, this is more important than length older adults without diabetes, PD
of life. Many tolerate hemodialysis (HD) and the associated and HD provide equivalent survival;
need for transport to and from a HD unit poorly. Yet in most in patients with diabetes, there is a
higher risk for death in older patients
parts of the world, older patients are preferentially placed on
treated with PD in some but not all
hospital-based HD and are considered unsuitable for a home- parts of the world
based self-care dialysis. Peritoneal dialysis (PD) would enable • Recent studies show that older adults
many of these older patients to have their dialysis treatment treated with PD have a higher risk for
in their own home and would enable them to travel. Many transfer to in-center HD than younger
patients would be able to do their own dialysis, and those patients in many different parts of the
who cannot or would struggle to do their own dialysis could world
be assisted by family or paid assistants. Assisted PD with paid • None of these studies should affect
assistants is increasingly available in many European countries decision-making for an individual
and Canada. patients as the effect of dialysis modality
With this background, the International Society for on lifestyle and quality of life is often
much more important to older adults
Peritoneal Dialysis (ISPD) has commissioned a series of
papers reviewing how to manage older patients on PD. They Selecting peritoneal • Successfully starting an older patient
focus on the general needs of the patient as well as specific dialysis on PD therapy is a multi-step process
dialysis issues. The papers reflect the views of experts and that includes assessment and
are not guidelines. There is a paucity of high-quality evidence determination of eligibility, offer of
PD to eligible patients, selection of
for dialysis management in general — and virtually none for
PD as modality of his/her choice, and
older patients, who are mostly excluded from nephrology trials ultimately, successful receipt of PD
because of their age and from trials in the general population • An interdisciplinary team is required
because of their renal impairment. An international group of to adequately assess and educate older
authors has contributed to the series of papers; all are known patients about PD as a modality option
for expertise in the topics on which they have written. The

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BROWN et al.
Topic Key points
Selecting peritoneal • Older patients have medical and social
dialysis (cont’d) conditions that influence the ability to
make it through each step of the process
• Barriers to PD can often be overcome
if adequate assistance is provided by
family members, home-care workers, or
staff in long-term care facilities
Unplanned-start • Late-referred patients with urgent need
peritoneal dialysis for dialysis are overrepresented among
the older ESRD population and are par­
ticularly likely to be started on HD with
a temporary central venous catheter
• Unplanned start on HD is associated
with excess mortality and increased
risks of potentially lethal infectious or
mechanical complications
• Unplanned start on PD may be associated
with increased risk of mechanical com­
pli­cations but apparently no detrimental
effect on mortality, PD technique failure
or risk of infectious complications
• Mortality after unplanned start on
PD seems to be equal to or less than
mortality after unplanned start on HD
• Unplanned start on automated PD is a
gentle, safe and feasible alternative to
unplanned start on HD
Training and support • Regular assessment of older patients is
of older patients essential and part of routine care
• Assessment of cognition, frailty, and
depression should be undertaken
• Regular communication with the patient
on their preferences and expectations
using advance care plans as necessary
is critical
• Research and evidence based on
support systems/rehabilitation
programs required to maintain older
patients at home should be developed
• Support for caregiver’s/family’s needs
to be integral part of the management
of older patients
Geriatric assessment • Geriatric assessment is critical in
and rehabilitation establishing what possible barriers are
present that may impact successful PD
and establishing a care plan to promote
maximal functionality
• Older patients established on PD have
a heavy degree of functional loss and
often need help even with personal care
• Older patients established on PD are at
high risk of falls
• The success of geriatric rehabilitation
in the PD population has not been
established, but there are no reasons
to suspect it would be different from
that seen in the HD population
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NOVEMBER 2015 - VOL. 35, NO. 6 PDI
Topic Key points
Geriatric assessment • The effect of assisted PD on changes
and rehabilitation in functional independence over time
(cont’d) remain unknown
Peritoneal dialysis • Older patients constitute a diverse
adequacy group of patients
• Care (including dialysis prescriptions)
must be individualized according to
patients’ expectations and wishes
• ISPD guidelines for PD Adequacy
(solute clearance and fluid balance)
will be appropriate for many older
patients even though very few studies
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cited have included patients with
advanced age
• Quality-of-life considerations mean
that escalation of PD dose may not be
appropriate for some older patients;
frequency and intensity of monitoring
solute clearance and peritoneal
membrane function can be reduced
• Principles of integrated care apply to
older patients on PD, although focus
may be more towards end-of-life care
planning rather than transplantation
however, suitable older patients should
not be denied the opportunity to
undergo modality switch to HD with
appropriate HD access planning
Chronic kidney Recommended prophylactic and
disease – mineral bone therapeutic interventions:
disease (CKD-MBD) • Prevention of hyperphosphataemia by
in older PD patient diet and phosphate binders
• Prevention of hypo- and hypercalcemia
by appropriate dose of active
vitamin D and dialysate calcium
concentration
• Vitamin D supplements to achieve
serum 25-hydroxyvitamin D levels of
>75 nmol/L (> 30 pg/mL)
• Low-dose active vitamin D to all
patients
• High protein intake, minimum
0.8 g/kg/day
• Exercise and physiotherapy, including
falls prophylaxis
Peritoneal dialysis • Heart failure frequently co-exists with
for heart failure renal impairment
• Ultrafiltration therapies represent a
potentially useful adjunctive treatment
for patients with severe heart failure
associated with frequent hospital
admissions
• Peritoneal dialysis is a gentle and
relatively cheap ultrafiltration therapy
that may reduce hospitalization and
improve survival in patients with severe
heart failure
PDI NOVEMBER 2015 - VOL. 35, NO. 6
Topic Key points
Peritoneal dialysis • There is a pressing need for randomized
for heart failure trial evidence with economic analysis
(cont’d) to better identify patients who may
benefit from PD as a treatment for
heart failure
The gut in older • The elderly experience reduced
PD patients appetite and often find reaching
caloric goals difficult
• Gastrointestinal symptoms are common
and under-reported in the elderly
• Constipation in PD patients is
associated with an increased risk of
peritonitis, and fibre supplements,
lactulose and polyethylene glycol
appear to be safe and effective as
treatments.
• Diverticulosis is common in the elderly
but may not preclude PD unless very
severe and symptomatic
• In the elderly, elevated intra-
abdominal pressures associated with
PD may exacerbate hernias, urinary
incontinence and uterine prolapse
Nutrition • Older adults are vulnerable to
malnutrition due to many non-
nutritional factors such as mood and
social circumstances
• Additional calories from the dialysate
can benefit those whose caloric intake
is compromised
• Preserving muscle integrity is
important in older adults; it is
therefore important to aim for
adequate protein intake and prevention
of metabolic acidosis
• Gastrointestinal-related symptoms are
likely to compromise nutritional intake
in older people on PD
• Limiting salt intake to less than 6 g per
day can help with volume control
Peritoneal dialysis- • With appropriate training and adequate
related infection support, the peritonitis rate of older PD
patients is highly acceptable
• In general, the recommendations for
the treatment and prevention of PD-
related infections by the ISPD should
be followed in older patients
• Older patients who develop peritonitis
have a high short-term mortality
• Older PD patients with multiple
comorbid conditions have an excessive
risk of relapsing peritonitis episodes
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MANAGING OLDER PATIENTS ON PD
Topic Key points
Peritoneal dialysis- • Technical problems, social difficulties,
related infection and concomitant comorbid diseases
(cont’d) often have substantial effects on
management of peritonitis in older PD
patients
Assisted peritoneal • Due to advanced age and the burden
dialysis of comorbidities, the growing group
of older patients with ESRD are usually
not candidates for home-based PD
• Some of the barriers for PD are non-
modifiable, but the majority may be
overcome provided that proper support
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and assistance are offered to the
patients at home
• In France and Denmark, the cost of
assisted PD is equal to the cost of
in-center HD
• Assisted PD may increase the number of
older patients actually treated with PD
at home and may reduce the risk of PD
technique failure and thus prolong the
duration of PD
• Dependency on help, on top of
advanced age and a heavy burden of
comorbidities, may be an independent
risk factor for poorer outcome
• Assisted PD is an evolving dialysis
modality and may in the future prove
to be a feasible complementary
alternative to in-center HD for the
growing group of dependent older
patients with ESRD
End of life • Patients want discussions about
prognosis and management at the end
of life
• Factors affecting prognosis include
age, comorbidities, nutritional status,
physical and cognitive function
• Symptoms should be recognized and
treated
• Ceiling of care – including resuscitation
status and dialysis withdrawal – should
be discussed with patients
• Targets of care (dialysis and medications)
should focus on current well-being and
not on long-term complications
Edwina A. Brown
Joanne M. Bargman
Philip K.T. Li
http://dx.doi.org/10.3747/pdi.2015.00159
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