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It has been predicted that the requirement for renal replacement therapy in the U.K. will increase by 50–100% within 15 years.1 This therapy is an expensive resource2 and unlimited access to treatment will prove difficult to fund. The number of persons aged >65 years is increasing in all developed countries, and this trend is projected to continue into the future.3 There is a steep rise in the incidence of end‐stage renal failure with age,4,,5 and much of the aforementioned rise in the requirement for renal replacement therapy relates to these demographic changes. Increased acceptance of older patients for replacement therapy in the UK is evidenced by a rise in the proportion of older persons (>65 years) from 11% to 41% between 1982 and 1995.6Nonetheless, a huge disparity in overall acceptance rates persists between the UK, Canada and the US. In England and Wales, the annual acceptance rates rose from 67 per million population (pmp) in 1982 to 82 in 1995.6 This compares poorly with 98 and 212 pmp in Canada7 and the US,8 respectively. Some (but not all) of this disparity is explained by a higher true incidence of end‐stage renal disease in the US and Canada.7,,8 Whether optimal access to renal replacement therapy is available to older patients in any of these jurisdictions is unclear. It could be that such therapy is excessively or inappropriately available to older patients in the US, without consideration of the likelihood of health or social gain to the individual patient. Alternatively, are older patients with renal failure being denied access to worthwhile treatment in the UK solely on the basis of their chronological age?A …

Rationing renal replacement therapy to older patients-agreed guidelines are needed