Background: The number of elderly patients reaching end-stage renal disease is increasing over time. This subset of patients and their families, as well as nephrologists and other physicians, have to make a difficult decision whether or not to start dialysis. Hence, evidences are needed to guide them in their decision-making for or against dialysis, especially in those patients affected by multiple comorbidities for which dialysis may not increase survival or may not improve the quality of life.

Methods: Medline, PubMed, EMBASE and Cochrane Library were searched for records in English from the year 2004 to 2014 using the following terms: End-stage Renal Disease, Dialysis, Conservative Management and Elderly. Bibliographies of included articles were also reviewed. All studies identified during the database search were assessed for relevance to the review based on the information provided in the title and abstract. Full copies of the articles were retrieved for all the studies that met the inclusion criteria. Data from all the chosen articles were then carefully appraised to come up with a descriptive analysis.

Results: Seven studies were included in this systematic review. In studies on survival rates, it was found that dialysis prolongs survival in the elderly more than that of the conservative management with a median survival of 39.5 months versus 18.9 months, respectively. However, it was observed that there is no significant difference in the survival rates between the two treatment modalities in patients who have multiple comorbid conditions. In terms of quality of life, there is no statistically significant difference between the two groups. However, patients who chose dialysis have lower satisfaction with life scale score and patients who opted for conservative management scored higher in terms of mental health and social functioning as compared to those who chose dialysis. Moreover, patients managed with conservative management have less hospitalization rates and they most likely die at home or in a hospice. Thus, while patients may live longer with dialysis, they can expect to spend a significant proportion of that time in a medical setting. Patients and their families differ at how they prioritize between prolonging life versus maximizing time at home and these preferences are important to elicit when discussing dialysis initiation.

Conclusion: In patients 70 years and above with end-stage renal disease, dialysis offers a higher survival rate over conservative management. However, the survival advantage of dialysis is substantially reduced by the number of comorbid conditions most especially ischemic heart disease. Furthermore, in this subset of patients, those who chose to maximize conservative management maintained quality of life comparable with those patients on long-term dialysis but with more hospital-free days and higher life satisfaction. These findings show that conservative management is a valid treatment option for selected patients.

Keywords: dialysis, conservative management, elderly, end-stage renal disease  

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