The first problem faced by elderly patients with end-stage kidney disease is deciding whether to start renal replacement therapy. When performing conservative treatment for chronic kidney disease in the elderly, not only the decrease in renal function but also the characteristics of the elderly should be considered. Although complication management guidelines for chronic kidney disease are continuously revised and published, separate guidelines are not provided for elderly patients over 65 years of age, unlike children. In clinical studies related to new drugs or existing drugs, it is difficult to produce guidelines based on evidence, even though they have characteristics different from those of ordinary adults, as there are not many cases where people over the age of 65 are included. Until now, the meaning of conservative treatment for chronic kidney disease in the elderly includes drug treatment, diet control, and comorbidity management, except for dialysis, and refers to treatment applied before dialysis. Once we have decided on renal replacement therapy, we should choose the most appropriate dialysis method. According to the “ESKD-Life-Plan” of the K/DOQI 2019 guidelines, it is necessary to establish an individualized plan in consideration of the patient's situation, medical/living environment, and patient's preferences. According to the report of the 2020 Korean Nephrology Association, there is no difference in the 5-year survival rate (61.5% vs. 61.7%) and 10-year survival rate (40.7% vs. 39.0%) between hemodialysis and peritoneal dialysis. The choice of dialysis method according to preference has become important. In addition, patients who choose to undergo conservative treatment should treat the accompanying disease, control symptoms, and consider psychological support. In order to apply this concept, it is necessary to implement shared decision making through close consultation among patients, families, and medical staff.