Dialysis dependence is associated with marked reduction in health-related quality of life (HRQoL) compared to age-matched controls, a finding seen in both North American and international populations [79]. Cross sectional studies have suggested that peritoneal dialysis is associated with improved HRQoL compared to hemodialysis in the general population [80]. While this finding suggests that peritoneal dialysis may be the preferred modality for many patients, it may be related to selection bias, and in any case is difficult to apply to the elderly population, who frequently have difficulty adhering to the self-care requirements. Further, any initial advantage in HRQoL may not be sustained; an observational study focused on elderly patients found that while initial HRQoL was higher in the PD population, this advantage was not evident at 6 and 12 months after dialysis initiation [18].

For hemodialysis patients , in particular, the causes for reductions in quality of life are likely multifactorial. Pain and depressive symptoms can drive lower mental health scores, and also lead to shortened hemodialysis treatments, increased utilization of emergency services, and hospitalizations [81]. In the recently published Frequent Hemodialysis Network trial, 245 patients were randomized to standard thrice weekly dialysis or a more frequent schedule of dialysis six times per week, with shorter daily sessions. The more frequent schedule was associated with improved self-reported general mental health, although depression scores were not significantly different. Possible mechanisms for this finding include better small molecule clearance, better volume management, reduced inflammation, and more convenient timing of dialysis [82].

Another issue to consider is the impact on caregivers. This is particularly relevant for peritoneal dialysis patients due to the significant home-care that is required. In one observational study of 201 elderly patients, the caregivers for 84 hemodialysis patients were compared to 40 peritoneal dialysis patients, who were both compared to a control group of caregivers of 77 non-elderly hemodialysis patients. Caregivers of peritoneal dialysis patients scored significantly lower on the mental component of the SF-36 than caregivers of hemodialysis patients. The authors hypothesized that this may be related to the challenges of repetitive dialysis exchanges and other medical responsibilities; these can be onerous and lead to feelings of anxiety, stress, resentment, and guilt [83].

While there have been multiple studies investigating the difference in HRQoL between PD and HD, the HRQoL related to hemodialysis access (i.e., AVF vs. AVG vs. TDC) has not been studied as extensively. The existing measures, including the CHOICE Health Experience Questionnaire (CHEQ ) and Kidney Disease Quality of Life (KDQOL), have only a handful of broad questions exploring dialysis access type [84, 85]. More recently, the short-form vascular access questionnaire (SF-VAQ ) was developed. This is a validated questionnaire evaluating patient satisfaction in a Canadian setting associated with HD access type. HD through an AVF was associated with the highest overall satisfaction, followed by TDC, with AVG having the lowest scores. Interestingly, the study determined that while AVF scored well in terms of outcomes like concerns around hospitalization and bathing, TDC was preferred when it came to physical complaints like pain, bleeding, swelling, and bruising [86].

Recently, quality of life considerations have been explicitly referenced in contemporary guidelines for the management of patients with ESRD [87]. However, there may still be tension between what might be recommended in guidelines and what an individual patient may find preferable, especially in the elderly [88].

Guidelines for ESRD patients often present a uniform approach to management, prioritizing interventions to reduce mortality and manage disease complications. The overall goal is to provide a simplified pathway to guide management rather than address complex issues that may develop for individual patients. Many ESRD patients have multiple comorbid conditions , which can generate conflicting treatment recommendations [89]. In older patients, an individualized approach that considers competing sources of morbidity and mortality can inform clinical decisions. Clinicians, in conjunction with patients and caregivers, can prioritize patient-centered outcomes, even if these outcomes may not be easily explained by a well-described disease process [90].