Dragos Scripcariu, Andreea Covic, Loredana-Mariana Agavriloaei, Bogdan Dumitru Agavriloaei, Teodora Joghiu, Mihai Onofriescu, Alexandru Burlacu, Luminița Voroneanu, Mehmet Kanbay, Adrian Covic
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.