Dialysis decision-making in severe frailty — ESENeph MCQ

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HardAdult-Paediatric Interface and EthicsDialysis decision-making in severe frailtyESENeph

A 74-year-old man with CKD G5 is being assessed for dialysis modality. He has severe dementia, recurrent aspiration pneumonia and requires two carers for transfers. His family asks about burdens and benefits of dialysis. What is the most appropriate management?

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Correct answer: D — Best-interests discussion including conservative kidney care

Advanced cognitive impairment and high comorbidity require careful discussion of expected benefits, burdens and alternatives, including active supportive kidney care. Dialysis may not improve quality or length of life in some frail patients and should be considered in the context of goals and best interests. Transplant assessment is not realistic in this scenario. The pearl is that modality counselling must include the option of non-dialysis care when clinically appropriate. The competing options do not fit the renal phenotype, temporal relationship, treatment threshold or safety constraint described. Management still requires confirmation of current medicines, renal trajectory and relevant contraindications, followed by timely biochemical and clinical reassessment. Escalate urgently if life-threatening electrolyte disturbance, respiratory compromise, shock, neurological deterioration or a dialysis indication develops.

Reference: NICE NG107; Renal Medicine 2022 Curriculum: https://www.gov.uk/government/publications/dialysis-guidance/dialysis-guidance