Dialysis versus conservative kidney management in older adults: why one size does not fit all

Abstract Background As the global population ages, an increasing number of older adults progress to end-stage kidney disease (ESKD). In this population, frailty, multimorbidity, and functional decline often limit the survival benefit of dialysis, challenging the conventional approach to renal replacement therapy. Purpose To summarize current evidence comparing dialysis with conservative kidney management (CKM) in older adults with advanced chronic kidney disease (CKD), focusing on survival, quality of life, hospitalization, and prognostic tools. Methods A narrative synthesis was conducted based on observational, cohort, and systematic review studies including adults aged ≥ 70 years with stage 4–5 CKD. The literature search was performed exclusively in the PubMed database, which represents a methodological limitation of this review. Search terms included: end-stage renal disease, chronic kidney disease, kidney failure, dialysis, conservative management, frailty, geriatric patients, and elderly patients. Outcomes were grouped into four domains: survival, quality of life, healthcare utilization, and prognostic models. Results Across studies, dialysis prolonged survival mainly in younger and less comorbid patients, but this advantage diminished with increasing frailty and multimorbidity. CKM provided comparable or superior health-related quality of life (HRQoL) and was associated with fewer hospitalizations. Patients managed conservatively were more likely to die at home, reflecting closer alignment with end-of-life preferences. Prognosis was primarily determined by patient-level factors—age, frailty, and eGFR decline—rather than by treatment modality. CKM-specific prognostic models remain limited. Conclusion In older adults with advanced CKD, survival gains from dialysis are modest and frequently offset by higher treatment burden. CKM offers a patient-centered alternative focused on quality of life, comfort, and goal-concordant care. The development of validated CKM-specific prognostic tools is essential to support individualized, evidence-informed decision-making.