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The number of older people with end-stage renal disease (ESRD) will inevitably rise. The population is ageing and chronic kidney disease (CKD) is predominantly associated with increasing age. CKD most commonly occurs alongside other diseases or as a complication of another chronic disease, most commonly diabetes or generalized vascular disease. 'Older people'is a very vague term and encompasses individuals in their 80s leading an active lifestyle with little disease burden and those who may be much younger but who are frail and have considerable medical and/or psychosocial disabilities. Most older individuals are aware that they have limited life expectancy and many will have made some plans for death in terms of wills, funeral plans or thinking about progression of disease. Doctors, however, are not good at discussing end of life plans with patients, at considering how active interventions, such as dialysis, will affect patient well-being, whether such interventions will extend life or even shorten it because of complications. For many older individuals, quality of life, being able to maintain independence and achieving lifestyle goals are more important than length of life, particularly if the extra length is achieved by treatments burdened with complications and time away from home. It is not surprising, therefore, that there is a movement emphasizing the merits of a patient-centered, rather than a disease-centered, approach to older patients with CKD [1,2].
Implications of diagnosis of CKD
People do not present to their general practitioner saying, 'I have symptom x and am worried that I have kidney disease,'even when they have symptomatic advanced kidney disease. Most commonly, CKD is an incidental finding as a result of routine blood or urine testing in the community or when monitoring another chronic condition such as diabetes or heart failure. When referred to a renal clinic, many patients do not know the reason why and are surprised when told they have problems with their kidney function. It is often forgotten that only a tiny proportion will progress to end-stage renal disease; after 8 years of follow-up, Hallan et al. found that only 38 of 3069 people in Norway with CKD developed ESRD, with risk being particularly low in those over 70 years old [3]. Even comparatively few patients with CKD 4 (estimated glomerular filtration rate:...