Criteria for initiating renal replacement therapy, with special emphasis on the elderly in our country

The textbook threshold. As CKD progresses and creatinine clearance falls to about 25 mL/min the full picture of uraemia appears; when the GFR falls below 10 mL/min it is necessary to start replacement therapy — dialysis or transplantation. Age itself does not constitute a contraindication to dialysis and/or transplantation.

Absolute and urgent indications — mnemonic "AEIOU". Acidosis, severe and refractory to bicarbonate. Electrolytes — refractory hyperkalaemia. Intoxications that are dialysable — lithium, salicylate, methanol, ethylene glycol, metformin. Overload — refractory pulmonary oedema unresponsive to diuretics. Uraemic complications — pericarditis, encephalopathy, neuropathy, intractable nausea and vomiting, and bleeding diathesis. Any one of these mandates dialysis regardless of the eGFR number.

Elective, planned initiation is symptom-driven, not number-driven. The trigger is a cluster of anorexia, nausea, weight loss, fatigue, declining functional status, uncontrolled fluid or blood pressure and progressive malnutrition, typically at an eGFR of 5–10 mL/min/1.73 m². Vascular access should be created well ahead — plan the arteriovenous fistula at an eGFR of about 15–20, as it needs weeks to mature and is harder to create in the elderly.

Geriatric modifiers of the decision. Predictors of a poor outcome on dialysis are poor nutritional status, dementia, gait disorders, impaired ADLs and IADLs, and late nephrology referral. Median survival on haemodialysis is 15.6 months at 80–84 years and 11.6 months at 85–89 years; the leading causes of death are elective withdrawal (38%), cardiovascular events (24%) and infection (22%). The survival gain must therefore be weighed against dialysis burden, travel, hospital time and loss of independence.

Transplantation remains on the table. Age alone does not exclude it: in the elderly, one-year patient survival is about 85% and one-year graft survival about 75%, with five-year functional graft survival of 55–60% in those over 60. Comorbidity, not the birth date, decides.

Three pathways, chosen by shared decision-making. Present haemodialysis, peritoneal dialysis (including assisted or automated forms for the more vulnerable, such as nursing-home residents) and conservative kidney management as genuine alternatives. Discuss prognosis honestly, undertake advance care planning, and where uncertainty remains, offer a time-limited trial of dialysis with an agreed review point. Genuine barriers in the very old are advanced dementia with inability to cooperate, terminal malignancy, unmanageable haemodynamic instability, absence of a carer for peritoneal dialysis, and the patient's own refusal — none of which is age. Advanced CKD in an older adult ↓ Any AEIOU indication? No urgent indication Yes → urgent dialysis regardless of → assess frailty, cognition, ADL/IADL, eGFR nutrition, social support ↓ Fit / independent Frail / dependent / demented Plan access at eGFR 15–20 · start on Offer conservative kidney symptoms at eGFR 5–10 · consider management or a time-limited dialysis transplant trial LATEST UPDATE (2023–PRESENT) — 1 POINT

The Indian picture — access has improved, but the decision framework has changed more. The Pradhan Mantri National Dialysis Programme under the National Health Mission provides free haemodialysis at district hospitals in public–private partnership mode, with an explicit policy push to expand peritoneal dialysis because it is home-based, needs no thrice-weekly transport and is haemodynamically gentler — all decisive advantages for the very old. AB-PMJAY covers dialysis packages, and the Ayushman Vay Vandana Card extends cover to all citizens aged 70 and above irrespective of income. Practical Indian barriers persist: distance and transport for thrice-weekly haemodialysis, caregiver availability for peritoneal dialysis, out-of-pocket cost of erythropoietin and drugs, and very low rates of transplantation in the elderly. Contemporary international practice — now reflected in Indian nephrology and geriatrics guidance — is to start on symptoms rather than on an eGFR number, and to present conservative kidney management as an explicit third option, supported where available by state palliative networks such as Kerala's community palliative care programme.