For years, your mom's doctor has mentioned her "kidney numbers" at checkups. Now the nephrologist says her kidneys are failing and it's time to talk about dialysis. She's 84, has heart problems and already tires easily. She asks you, quietly, whether she really has to do this. You aren't sure what to tell her.
Kidney failure is common in older adults, often after years of diabetes or high blood pressure6. It's serious, but there are real choices, including treatment focused on comfort rather than dialysis2. This guide explains what happens when kidneys fail, the symptoms, each treatment path and how families can help. It's general information. Your parent's kidney team can explain what fits their health and wishes.
What kidney failure means
Healthy kidneys filter waste and extra fluid from the blood, help control blood pressure, keep bones healthy and help make red blood cells6. Chronic kidney disease (CKD) means the kidneys are damaged and slowly losing function. Kidney failure, also called end-stage renal disease or ESRD, is the last stage, when the kidneys work at less than about 15 percent of normal1.
The most common causes are diabetes and high blood pressure6. See diabetes in the elderly for how families can help with blood sugar control. Kidney function also tends to decline with age, which is one reason CKD is so common in older adults. Many people with early CKD have no symptoms, so it is often found through routine blood and urine tests6. Blood pressure control protects the kidneys; see high blood pressure in the elderly.
Symptoms of kidney failure in older adults
As waste and fluid build up, people may notice17:
- Tiredness and weakness. Often from waste buildup and anemia.
- Swelling. In the legs, ankles, feet or around the eyes.
- Poor appetite and nausea. Sometimes a metallic taste or vomiting, and weight loss.
- Itchy skin. Which can be constant and bothersome.
- Shortness of breath. From fluid in the lungs or anemia.
- Muscle cramps and restless legs. Often at night.
- Trouble sleeping or concentrating. Including new confusion in some older adults.
- Changes in urine. Making more or less urine than usual.
In older adults, these symptoms can be mistaken for aging, heart problems or medicine side effects. Keep a simple log of symptoms and share it at appointments. Kidney failure also often happens alongside heart failure, since each can strain the other. If your parent has both, see congestive heart failure in the elderly, and ask the kidney and heart doctors to share notes so fluid and medicine plans agree. Our guides to an elderly parent sleeping a lot and dehydration in older adults cover other causes of tiredness and confusion.
Stages of chronic kidney disease
Doctors stage CKD from 1 to 5, mainly using a blood test called eGFR, which estimates how well the kidneys filter6. Stages 1 and 2 involve mild damage with near-normal filtering. Stage 3 means moderate loss of function, stage 4 means severe loss, and stage 5 is kidney failure6. A urine test for protein also helps show how much damage there is.
Not everyone with CKD reaches kidney failure. Many older adults stay at stage 3 for years, especially when blood pressure and blood sugar are well controlled6. Ask the doctor which stage your parent is in, how fast their numbers are changing, and what can help slow the decline.
When to call the doctor
- Call the kidney team for quick weight gain or more swelling.
- Call for vomiting, not eating, or very little urine.
- Call for fever, redness or drainage at a dialysis access or catheter site.
- Call if a medicine change seems to make your parent drowsy or confused.
Treatment choices for kidney failure
When kidneys fail, there are four main paths2. Your parent can talk through each with their nephrologist, and can change course later.
- Hemodialysis. A machine filters the blood. It's usually done at a dialysis center about three times a week for about four hours each time, or sometimes at home8.
- Peritoneal dialysis. Uses the lining of the belly to filter the blood, with fluid exchanged through a catheter. It's done at home, often overnight with a machine9.
- Kidney transplant. Possible for some older adults in good overall health, after a careful evaluation2.
- Conservative management. Care without dialysis or transplant, focused on managing symptoms and quality of life3.
Medicare covers kidney disease education sessions for people with stage IV CKD, which help families understand these choices before decisions are urgent5.
What life on dialysis is like for an older adult
Dialysis can ease symptoms and extend life for many people. It's also a big commitment. In-center hemodialysis means regular trips, hours in a chair and tiredness afterward for some people8. Diet and fluid limits usually continue. Before dialysis starts, a surgeon usually creates an access in the arm, which takes time to heal.
Families often help with transportation, scheduling and watching for problems such as infection at the access site, low blood pressure or cramps. Ask the dialysis unit's social worker about transportation help and support groups. Home dialysis offers more flexibility but needs a capable helper or a person who can do it themselves9.
Choosing care without dialysis
Conservative management, sometimes called medical management without dialysis, is a real treatment choice3. The kidney team keeps treating symptoms, anemia, fluid and blood chemistry with medicines and diet, and focuses on comfort and daily life.
For some older adults, especially those with several other serious health problems or frailty, dialysis may not lengthen life by much and can add burdens3. Others decide that time at home with family matters more than time in a dialysis chair. People who choose this path can still live for months or longer, depending on their health. Palliative care can support them throughout10.
This is a personal decision. It helps to ask the doctor: "What would dialysis likely mean for Mom's daily life, and how much time might it add?" and "What would comfort-focused care look like?"
Daily care and support at home
- Help with medicines. Many medicines need dose changes when kidneys fail. Keep an updated list and ask before using any new pill, including over-the-counter pain relievers.
- Follow the kidney diet. A dietitian may suggest limits on salt, potassium, phosphorus and fluids. Read labels together1.
- Watch weight and swelling. Sudden weight gain may mean fluid buildup.
- Keep skin comfortable. Moisturizers and medicines from the doctor can ease itching.
- Prevent falls. Weakness, cramps and blood pressure drops after dialysis raise fall risk. See fall prevention for older adults.
- Protect mood. Depression is common with long-term illness. See depression in older adults.
If your parent needs help at home after a hospital stay, read does Medicare pay for home health care and home care vs. home health.
How Medicare helps with kidney failure
Most people 65 and older already have Medicare. Medicare covers dialysis treatments, supplies and related services, whether in a center or at home, and kidney transplants for people who qualify411. People under 65 with kidney failure may also qualify for Medicare because of ESRD11.
Ask the dialysis unit's social worker to review your parent's coverage, including any supplemental plan, and to explain what costs your parent may still owe. A State Health Insurance Assistance Program counselor can also help at no charge12.
Kidney failure in assisted living or a nursing home
Many residents of assisted living and nursing homes have kidney disease. If your parent is on dialysis, ask any community how residents get to dialysis, whether it handles kidney diets and fluid limits, and whether staff know how to check an access site. Some nursing homes offer dialysis on site. If your parent chooses conservative care, ask how the community works with palliative care and hospice. See assisted living vs. nursing home and hospice in assisted living.
End-stage kidney failure and comfort care
Near the end of life, whether after stopping dialysis or with conservative care, people with kidney failure often become more tired and sleepy, eat little, may have more swelling or itching, and may become confused7. Good comfort care can ease these symptoms.
Hospice is available when a doctor certifies a life expectancy of six months or less if the illness runs its normal course13. People who decide to stop dialysis can choose hospice, and families should talk with the kidney team and hospice about what to expect. Read end-of-life signs in the elderly, what hospice provides and hospice vs. palliative care.
Questions to ask the kidney team
- What stage is my parent's kidney disease, and how quickly is it changing?
- What would dialysis mean for their daily life, energy and independence?
- How might dialysis change how long they live, given their other health problems?
- What would conservative care look like, and who would provide it?
- Is home dialysis possible, and what help would we need?
- Can palliative care start now, alongside other treatment?
Bring a notebook or ask if you can record the conversation, and invite your parent to ask their own questions first. If your parent has trouble hearing or remembering, ask for written answers and a printed care plan to take home.
Talking about choices as a family
Decisions about dialysis are deeply personal. Some older adults want every treatment; others value comfort and time at home most. Ask your parent what matters most to them, what they fear, and what a good day looks like. Their answers can guide the medical plan. Record their wishes in an advance directive14, and see advance directive vs. living will.
Siblings may disagree. A family meeting with the kidney team or a palliative care doctor can help everyone hear the same information. Caring for someone with kidney failure is demanding, so make room for your own rest. See caregiver burnout.
