The prevalence of chronic kidney disease (CKD) increases substantially with age. Coincident changes in patient priorities and prevalence of frailty and comorbidity create unique challenges for decision making for older individuals with advanced CKD. Older adults are often unable to obtain a kidney transplant, suffer higher rates of complications after dialysis initiation, and may not experience improved survival or well-being with dialysis as compared to conservative kidney management when they are frail and have other serious comorbidities.