Exploring Predictors of Quality of Life in Older Adults With End-Stage Kidney Disease Receiving In-Center Hemodialysis: A Cross-Sectional Analysis of Sociodemographic, Dialysis-specific, Biopsychosocial, and Activity-Related Factors

The global prevalence of end-stage kidney disease (ESKD) is steadily rising, with older adults representing the fastest-growing demographic in this patient population. In Europe, individuals aged 65 and older now account for over 52% of all incident ESKD cases. The primary treatment modality, in-center hemodialysis (ICHD), although life-sustaining, imposes a considerable treatment burden. This burden, when combined with the inherent symptom load of advanced kidney disease, often leads to a significant reduction in patients' overall well-being.

Compared to their younger counterparts, older adults on dialysis experience more complex clinical trajectories, characterized by multi-morbidity, increased frailty, and psychosocial vulnerability. Moreover, this population often faces challenges in adhering to the demanding schedules and lifestyle restrictions associated with dialysis. These factors collectively contribute to a reduction in overall quality of life (QoL), which patients often prioritize even over life expectancy.

Numerous studies have demonstrated that many older dialysis patients are willing to trade significant lengths of life expectancy, up to nine years in some cases, in exchange for better QoL. Despite this, QoL remains a vastly underutilized metric in nephrology clinical research. Only a small fraction of randomized controlled trials include QoL as an outcome measure, and even fewer consider it as a primary endpoint.

Health-Related Quality of Life (HRQoL), a narrower construct within the broader domain of QoL, is often used as a proxy for evaluating the well-being of patients. However, HRQoL tools may not fully capture what matters most to patients, especially during major life transitions such as dialysis initiation. Furthermore, differences in HRQoL instruments can produce inconsistent evaluations of patient outcomes and influence the estimation of quality-adjusted life years (QALYs), potentially skewing health policy decisions.

In light of these concerns, there is a need to examine overall QoL among older adults receiving dialysis, moving beyond standard HRQoL assessments to capture a more holistic and patient-centered understanding of life quality in this vulnerable population.