Deciding between conservative kidney management and dialysis in older people with kidney failure: a narrative review

ABSTRACT

The global population is ageing, and chronic kidney disease is becoming more common. As a result, increasing numbers of older adults with multimorbidity and frailty are progressing to kidney failure. This requires all healthcare professionals involved in the care of people with kidney failure to be able to provide careful guidance with regards to available treatment options. Choosing a treatment pathway for frail patients may be challenging, particularly for those considered ineligible for kidney transplantation. For such individuals, the remaining options are dialysis and conservative kidney management (CKM). However, these treatments have not been compared in randomized trials, which often makes it difficult to determine which treatment best aligns with the needs and preferences of people living with kidney failure.

In this narrative review, we discuss CKM as a valuable treatment approach for old and frail people with kidney failure, and those considered ineligible for kidney transplantation. We compare clinical outcomes between CKM and dialysis, such as health-related quality of life and survival. We guide the identification of people who may benefit from CKM and when discussions on CKM should be initiated. We discuss shared decision-making and consider the perspectives of patients, caregivers, and clinicians. Lastly, we embed CKM within the broader context of kidney supportive care, a palliative approach that includes advance care planning, symptom management, and lifestyle modifications that can be considered irrespective of treatment modality. Regardless of whether CKM or dialysis is chosen in the end, careful consideration of treatment options can help to ensure that people with kidney failure receive care that aligns with their values, preferences, and goals.

WHY CONSERVATIVE CARE IS NEEDED AS A TREATMENT PATHWAY

As a result of the ageing population and the increasing global prevalence of chronic kidney disease (CKD), a growing number of older people with substantial multimorbidity and limited life expectancy will progress to kidney failure [1–4]. These older people with kidney failure are often deemed ineligible or too frail to undergo kidney transplantation. The remaining treatment options are dialysis and conservative kidney management (CKM), but due to a scarcity of high-quality comparative evidence, informed benefit–risk assessment when choosing between these treatments is challenging. Against this background, care for people with kidney failure may be considered within a holistic care model where both CKM and dialysis are viewed as viable treatment options. Importantly, CKM should not be framed as the absence of active treatment, but as an intentional, proactive care pathway aligned with patient goals and priorities [5, 6]. In addition, opting for the most appropriate treatment may avoid unwanted medical interventions. This may benefit the individual patient as well as society by reducing potentially burdensome treatments and lowering health care costs and environmental impact [2, 7, 8]. To that end, all kidney care professionals should be equipped to inform, support, and empower patients and their caregivers when choosing between CKM and dialysis treatment.

The purpose of this narrative review is to guide clinicians through the available evidence on CKM. First, survival, health-related quality of life (HR-QoL), and symptom burden are compared between CKM and dialysis treatment. Second, we discuss strategies to identify patients in whom CKM may be most appropriate, when to initiate discussions about choosing between CKM and dialysis, and how to incorporate various perspectives through shared decision-making. Lastly, CKM is discussed within the broader framework of kidney supportive care, a person-centred approach that incorporates palliative care principles, irrespective of the treatment pathway chosen (Box 1). Within this perspective, we address advance care planning, symptom management, and lifestyle modifications, preferably provided by a multidisciplinary care team. Taken together, this review provides a practical overview of CKM to familiarize clinicians with key elements involved in the day-to-day care of people with kidney failure opting for CKM.

Box 1.

Conservative Kidney Management within Kidney Supportive Care

Conservative kidney management (CKM) is defined as care for people with kidney failure that focuses primarily on trying to optimize quality of life by proactively managing symptoms and preserving residual kidney function, without incorporating kidney failure replacement therapy [6].

Kidney supportive care is a holistic and palliative care approach that includes symptom management, spiritual care, and advance care planning to optimize the HR-QoL of people living with kidney failure, irrespective of the treatment pathway chosen [6]. Kidney supportive care acknowledges that medical outcomes need to be balanced and sometimes deprioritized to meet the patient´s preferences and goals of care.

Integration of kidney supportive care across treatment pathways. For patients receiving CKM, kidney supportive care is an integral component of treatment from the beginning. In contrast, for patients treated with dialysis or living with a kidney transplant, kidney supportive care can and should be incorporated when clinically indicated. This may be prompted by increasing frailty or limited life expectancy, but can also be anticipated earlier, particularly when dialysis is initiated without the prospect of kidney transplantation.

HEALTH-RELATED OUTCOMES OF CONSERVATIVE KIDNEY MANAGEMENT VERSUS DIALYSIS

Health-related quality of life and symptom burden

Findings on HR-QoL in people with kidney failure receiving CKM, relative to dialysis, are extremely heterogeneous. A non-systematic selection of key studies is shown in Table 1. Whereas some studies suggest that patients opting for CKM experience worse HR-QoL and symptom burden, other studies have found similar or in other cases more favourable HR-QoL and symptom burden in patients with CKM compared to those receiving dialysis [9–19]. Cohort studies further demonstrate that, in general, mental well-being is often relatively preserved under CKM, albeit frequently accompanied by lower physical functioning [20–23]. Importantly, physical health status alone does not fully capture the lived experience of older people with kidney failure. For many individuals, a lower treatment burden, continuity of care, and emotional well-being may outweigh potential disadvantages related to physical functioning.

Table 1:

Non-systematic review of key studies comparing health-related quality of life outcomes in conservative kidney management and dialysis.

Author, Year (N)	Study type	Setting/era	Inclusion criteria	HR-QoL measure	Other PRO measure	Cohort	HR-QoL findings	Other patient-related outcomes	Takehome message
Chou (2023) [18] (n = 510)	Prospective cohort	Australia2009–18Single centre	≥65 years, CKD G4–5 CKM or on dialysis	n.a.	IPOS (Renal)	CKM n = 280, mean age 84 years; dialysis n = 230, mean age 74 years	n.a.	Symptom burden more often improved in CKM at 12 months FU	Symptom burden may improve in CKM over time with kidney supportive care
Martino (2024) [16] (n = 50)	Case–control	Italy2022–23Single centre	≥75 years, CKD G5 on CKM or dialysis for ≥6 months	SF–12	Pain VAS	CKM n = 25, mean age 82 years; HD n = 25, mean age 81 years	PCS and MCS higher in CKM at 6 months follow-up	Pain comparable	CKM shows better perceived HR-QoL over time
Mathew 2023 [17] (n = 131)	Cross-sectional	South Africa 2020–21Single centre	CKD G5, CKM or on dialysis for ≥3 months	KDQOL-SF	HADS	CKM n = 31, mean age 60 years; HD n = 50, mean age 46 years; PD n = 50, mean age 44 years	PCS lower in dialysis; MCS similar	Higher anxiety in HD	CKM better physical HR-QoL
So (2022) [23] (n = 604)	Retrospective cohort	Australia2014–20Single centre	CKD G5, CKM or on dialysis	EQ–5D–5L	n.a.	CKM n = 144, median age 82 years; HD n = 265, median age 69 years; PD n = 59, median age 69 years	Lower physical functioning in CKM; no changes over time	n.a.	QoL remained stable across modalities, but lower physical on CKM
Da Silva-Gane (2012) [20] (n = 170)	Prospective cohort	UK2005–10Single centre	CKD G4–5, CKM or on dialysis	SF–36	HADSSWLS	CKM n = 30, mean age 78 years; HD n = 80; mean age 61 yearsPD n = 44 mean age 48 years; not decided n = 16, mean age 68 years	Lower physical health in CKM, similar mental health at 1 year FU, no changes over time	Higher anxiety in CKM, but not after adjusting for confounders, no differences in depression or life satisfaction	CKM maintains stable HR-QoL over time despite but lower than dialysis patients
Iyasere (2019) [19] (n = 84)	Cross-sectional	UK2014–16Multicentre	≥60y, eGFR <10 ml/min/1.73 m2, CKM or on dialysis	SF–12	HADSPOS–S (Renal)	CKM n = 28, median age 83 years; HD n = 28, median age 82 years; assisted PD n = 28, median age 81 years	PCS higher in PD; MCS similar	Lower depression in HD, lower symptom burden in PD	QoL broadly similar; PD with advantage in physical domain
Seow (2013) [15] (n = 101)	Prospective cohort	Singapore2007–09Single centre	≥75 y and CCI ≥8* eGFR 8–12, CKM or on dialysis	KDQOL-SF	n.a.	CKM n = 63, median 60; dialysis n = 38, median age 60 years	PCS stable in CKM over 18 months FU, lower at 24 months; MCS lower on dialysis	n.a.	Dialysis may not confer HR-QoL advantage in older and more comorbid populations
Zukiman (2017) [24] (n = 187)	Cross-sectional	Malaysia2015–16Multicentre	CKD G5, CKM or on dialysis for ≥1 years	n.a.	DSIDASS-21	CKM n = 100, mean age 61 years; dialysis n = 87, mean age 58 years	n.a.	Symptoms and psychological burden appear more common in CKM	Disease burden may be higher in CKM
Yong (2009) [22] (n = 179)	Cross-sectional	Hong Kong2006–07Single centre	CKD G5 CKM or dialysis for ≥3 months	SF–36	NRS for 23 symptoms	CKM n = 45, mean age 73 years; dialysis n = 134, mean age 58 years	Lower PCS yet apparently higher MCS in CKM	Higher pruritus and sexual symptoms in CKM	HR-QoL domains vary across groups; CKM mental domains preserved
Verberne (2018) [21] (n = 366)	Retrospective cohort	Netherlands2004–16Single centre	≥70 y, CKD G 4–5, CKM or on dialysis	KDQOL-SF	n.a.	CKM n = 126, mean age 83 years; dialysis n = 240, mean age 76 years	No differences after adjustment, besides lower treatment burden in CKM	n.a.	HR–QoL similar across modalities
Van Loon (2019) [25] (n = 281)	Prospective cohort	Netherlands2014–17Multicentre	CKD G5, CKM or on dialysis	EQ–5D–3L	n.a.	CKM n = 89, mean age 82 years; dialysis n = 192, mean age 76 years	Similar EQ–5D index; slight decline in CKM at 6 months FU	More pain in CKM; more anxiety in dialysis patients	Dialysis shows a slightly better HR-QoL trajectory
Shah (2019) [13] (n = 129)	Cross-sectional	UK & Australia2014–17Multicentre	≥75 y, CKD G5, CKM or on dialysis	SF–12 KDQOL-SF	ICECAP–O	CKM n = 46, median age 83 years; dialysis n = 83, median age 81 years	No differences in PCS or MCS	Dialysis patients have a higher burden of kidney disease	CKM associated with better well–being
McKeaveney (2023) [14] (n = 149)	Cross-sectional	UK2017–18Multicentre	>60 years, CKD G4–5, CKM or dialysis	KDQOL-SF	n.a.	CKM n = 75, mean age 74 years, dialysis n = 74, mean age 74 years	No differences in PCS and MCS	n.a.	No apparent overall dissimilarities between CKM or dialysis treatment

Abbreviations: CCI, Charlson Comorbidity Index; CKD, chronic kidney disease; CKM, conservative kidney management; DASS-21, Depression, Anxiety, and Stress Scale–21 items; DSI, Disease Severity Index; EQ–5D–3L, EuroQol 5 dimension 3 Level version; FU, follow-up; HADS, Hospital Anxiety and Depression Scale; HD, haemodialysis; HR-QoL, health-related quality of life. ICECAP, Investigating Choice Experiments for the Preferences of Older People; IPOS, Integrated Palliative Care Outcome Scale; KDQOL-SF; Kidney Disease Quality of Life Instrument Short Form; MCS, mental component score; n = number of patients; n.a., not applicable; PCS, physical component score; PD, peritoneal dialysis; POS–S (Renal), Palliative Care Outcome Scale-Symptoms Renal; PRO, patient-reported outcomes. SF–12, 12-Item Short Form Health Survey; SF-36, 36-Item Short Form Health Survey; SWLS, Satisfaction With Life Scale; VAS, Visual Analogue Scale; UK, United Kingdom.

The symptom burden appears to improve or remain stable under both CKM and dialysis treatment. Prospective studies suggest that symptom trajectories in patients managed conservatively may improve over time, or at least remain stable [18–20, 25]. Similarly, dialysis has been associated with symptom relief [26]. Comparative analyses between CKM and dialysis, however, yield mixed findings. Certain symptoms, such as pruritus or sexual dysfunction, have been reported more frequently among patients receiving CKM [22], whereas psychological symptom burden appears largely comparable between CKM and dialysis [17, 24]. While some studies describe differences in mental health outcomes, these are not consistently in favour of either treatment strategy [19, 20, 25].

Taken together, the available evidence suggests that CKM can be a viable option for maintaining an acceptable HR-QoL in people with kidney failure, although outcomes are highly individualized and dependent on patient characteristics and personal priorities. Although dialysis is associated with advantages in certain domains of physical functioning [17, 19, 20, 22, 25], these improvements do not consistently translate into better HR-QoL or mental health. This apparent equilibrium may, at least partly, be explained by the lower procedural, logistical, and treatment burden associated with CKM. These findings challenge the assumption that dialysis is uniformly superior in optimizing HR-QoL and symptom burden and underscore the need for comparative research to inform clinicians, patients, and caregivers on the effects of CKM and dialysis on HR-QoL and symptom burden.

Survival and hospitalisation

A non-systematic selection of key studies comparing survival between CKM and dialysis is presented in Table 2. Most observational studies report an association between dialysis treatment and longer survival compared with CKM [21, 25, 27–33], although several studies have demonstrated that this benefit is attenuated in very old or frail people [21, 25, 27, 29, 30]. Meta-analyses have largely corroborated these findings, indicating an overall survival advantage associated with dialysis, while also highlighting substantial heterogeneity across study populations and designs [12, 34, 35].

Table 2:

Non-systematic review of key studies comparing survival outcomes between people opting for conservative kidney management versus dialysis.

Author, Year (N)	Study type	Setting/era	Inclusion criteria	Exclusion criteria	Treatment pathways and starting point survival analysis	Patient characteristics including median age	Survival analysis dialysis vs CKM	Factors correlating with poor survival	Secondary outcomes
Murtagh et al. (2007) [27]n = 129	Observational, cohort from 4 centra within the same London region	UK2003–05Centra with multidisciplinary pre dialysis care, shared decision making	>75 year, predicted in need of dialysis within 18 months	First eGFR <15 ml/min/1.73 m2, incurable cancer, patients not referred to multidisciplinary clinics due to rapid progression.	Planned CKM vs planned dialysisTime to death from eGFR <15 ml/min	Dialysis n = 52Age 79.6, 65% maleCKM n = 77, age 83, 66% maleComparable DCS**	Better survival in dialysis group vs CKM, 1-year survival 84% vs 68% (P < .001)Survival benefit lost when DCS = 2	Age, comorbidity score (DCS) and ischemic heart disease	n.a.
Carson et al. (2009) [28]N = 202	Prospective observational, single centre trial	UK1997–2003	>70 years, dialysis initiation (acute kidney injury and listed for transplant included) or choosing CKM	none	Dialysis vs CKMTime to death from dialysis initiation or corresponding ‘putative dialysis initiation date’ when reaching eGFR threshold 10.8 ml/min in CKM group	Dialysis n = 173, age 7568.8% maleCKM n = 29, age 8358.6% maleNo difference in CCI between groups	Longer survival in dialysis group (37.8 vs 13.9 months, P < .01)	n.a.	More hospitalization in dialysis group vs CKM (25 vs 16 days per year)
Chandna et al. (2011) [29]n = 844	Observational single centre trial	UK2000–2018Patient decision guided by a team including home visits	eGFR10-15 ml/min	eGFR<10 ml/min	Starting dialysis or receiving a kidney transplant vs CKMTime to death from eGFR <15	Dialysis n = 689Age 58.566.6% maleCKM n = 155Age 77.559.4% maleHigher comorbidity	Longer median survival in dialysis group vs CKM (67.1 vs 21.2 months, P < .001), survival benefit lost if age >75 and high comorbidity	Age >75, high comorbidity, diabetes mellitus	n.a.
Hussain et al. (2013) [30]n = 441	Observational single centre trial	UK2006–10Centre with in-depth discussion with physician and home visiting nurse	Patients >70 years, eGFR <20 ml/min with gradual progress, offered CKM or dialysis during predialysis education	Patients presented with CKD 5 or rapid progression (no time for education)No time to make decision or undecided	CKM with palliative consultant vs dialysisTime to death from eGFR <20, <15 and <12 ml/min/1.73 m2	Dialysisn = 269, age 7760% maleCKM n = 172Age 82, 51% maleLower albumin, more dementia and Higher CCI*	Better survival in dialysis, 1-year survival 72% vs 58% for eGFR <20, <15 and <12 ml/min (P < .001)Survival benefit lost for patients >80 years or WHO performance status ≥3 [36]	Age, comorbidity scores (CCI and WHO performance status) and not living independently	Relative risk for hospital admission Dialysis vs CKM 1.6 (1.14–2.13)Higher rates of death in hospital (69% vs 47%) and less use of palliative care services (0% vs 67%)
Tam-Tham et al. (2018) [31]n = 838	Observational cohort trial	Canada2002–13	>65 years, eGFR <10 ml/min for at least 90 days	Death or dialysis on or before index, transplanted	Dialysis or no dialysis treatment (including patients not referred to nephrology)Time to death from eGFR <10 ml/min	Dialysis n = 500, age 76, 54.6% maleCKM n = 338Age 83, 39.6% male, higher CCI	Better survival in dialysis vs CKMadjusted HR 0.59 (0.46–0.77) during first 3 years of follow up, no longer significant if follow up >3 years	n.a.	Higher all cause hospitalizationAdjusted HR 1.40(1.16–1.69)
Verbene et al. (2018) [21]n = 366	Observation, single centre, Netherlands	Netherlands2004–16Multidisciplinary team counselling	>70 years and chosen dialysis or CKM	If needing immediate dialysis initiation	Dialysis or CKMTime to death from 4 starting points: pathway decision, eGFR <20, 15 and 10 ml/min/1.73 m2	Dialysis n = 240, age 75.966% maleCKMn = 126, age 82.555% maleNo difference in DCS	Longer survival (about 2 times) in dialysis group from all four starting points eGFR <20 (P < .001), Survival advantage lost in age >80 and in patients aged >70 with DCS ≥3	Increasing age and higher comorbidity
van Loon et al. (2019) [25]n = 281	Prospective multicentre (17 hospitals) cohort study	Netherlands2014–17 Shared-decision making	>65 years and CKD5	No informed consent, terminal non-renal condition, eGFR >15 ml/min (these patients are approached again when <15 ml/min)	Index at dialysis (<3 weeks before and <2 weeks after initiation) or within 3 months after decision of CKM and if eGFR <15 ml/min	Dialysisn = 192(13% on Tx waiting list)Age 7567% maleCKM n = 89Age 8256% malesHigher eGFR at indexMore likely to live aloneNo difference in severe comorbidity or frailty	Higher mortality in CKM vs dialysis group, adjusted HR 2.12 (1.12–4.03)Results no longer significant in patients >80 years	n.a.	More hospitalisations in dialysis group vs CKM (50% vs 24% had ≥1 hospitalization in 6 months, P < .01)
Zheng et al. (2022) [33]n = 1295	Propensity score matched cohort study	The US2008–13. Population in Kaiser Permanente Northern California, a fully integrated healthcare delivery system	>70 years with heart failure and eGFR ≤20 ml/min/1.73 m2	Missing information on gender, <12 months of health plan membership, prior KRT, patients who developed cirrhosis or cancer during follow up.	Dialysis vs no dialysis treatmentTime from eGFR ≤20 ml/min/1.73 m2	Dialysisn = 34877.8 years49.5% menNo dialysisn = 94780 years46.5% menAfter matching (1:3) groups were similar	Lower mortality in dialysis vs not starting dialysis, adjusted HR 0.67 (0.54–0.83) but high rates of mortality in both groups.	n.a.	Higher percentage of death in hospital and lower percentage of palliative care in dialysis group (P < .001)
Chou et al. (2023)[32]n = 510	Single centre prospective observational trial	Australia2009–18Multidisciplinary team, shared decision making	>65 years, CKD 4–5	Acute kidney injury or on transplant waiting list	Dialysis vs CKM cared for in multidisciplinary teamTime to death from decision of CKM or dialysis initiation as well as eGFR <15 ml/min and <10 ml/min	Dialysis n = 230, 74 years66% maleCKM n = 280, 84 years, 56% maleHigher CCI	Longer median 1-year survival in dialysis vs CKM, (83% vs 53%, P < .001)No difference by age groups	Higher comorbidity index, presence of heart failure and poor nutritional status	Dialysis group had 2-fold rate hospitalization compared to CKM with 21 vs 9 days in hospital per year (P = .03)
Montez-Rath et al. (2024) [37]n = 20 440	Observational trial using Target Trial Emulation, pooled data from 99 trials	United States, 2010–18	>65 years and eGFR <12 ml/min	Prior KRT, listed or evaluated for transplantation, acute kidney injury	Dialysis initiation within 30 days vs later dialysis initiation or CKMTime to death from eGFR <12 ml/min	Dialysis n = 8554Age 75.798.7% maleCKM n = 96 881, age 78.898% male	No difference in survival, HR 0.99 (0.91–1.08)Survival benefit 60 days (3.5–108.8) s for dialysis group if aged >80Per protocol analysis: better survival in patients starting dialysis at eGFR <12 ml/min vs CKM, HR 0.74 (0.71–0.79)	n.a.	More time spent in hospital in dialysis group

Abbreviations: CCI, Charlson Comorbidity Index [38]; CKM, conservative kidney management; DSC, Davies comorbidity score [39]; eGFR, estimated glomerular filtration rate; HR, hazard ratio; n.a., not applicable.

A recent observational study by Chou et al. including people older than 65 years, reported a sustained survival advantage for dialysis over CKM at the time of modality decision and upon progression to key estimated glomerular filtration ratio (eGFR) thresholds below 15 and 10 ml/min/1.73 m² [18]. However, people opting for CKM were considerably older and had a higher comorbidity burden, underscoring the potential for residual confounding [18]. Conversely, a large-scale target trial emulation study by Montez-Rath et al. analysed survival among ∼20 000 older adults opting for dialysis or CKM upon reaching an eGFR below 12 ml/min/1.73m² and found only a modest survival benefit of 77.6 days associated with dialysis [37]. The generalizability of these findings is limited by the study’s inclusion criteria, notably the requirement for dialysis initiation within 30 days of reaching the eGFR threshold, which does not reflect routine clinical practice in many settings. In addition, the use of Veterans Affairs healthcare data, with 2% or fewer female participants, further limits the broader applicability of the results.

Studies examining hospitalization rates consistently report longer and up to twice as frequent hospital admissions among people receiving dialysis compared with those managed conservatively [25, 28, 30–32, 37]. Furthermore, two studies indicate that patients treated with dialysis are more likely to die in-hospital rather than at home and are less likely to receive palliative care compared with patients receiving CKM [30, 33]. Taken together, the available observational evidence suggests that dialysis is generally associated with longer survival compared with CKM, but this advantage appears to diminish substantially with increasing age, frailty, and comorbidity. Moreover, any survival gains are accompanied by a higher burden of hospitalizations and institutional care. In very old or frail patients, the magnitude and clinical relevance of a survival benefit from dialysis therefore remain uncertain and must be carefully weighed against treatment burden and patient priorities.

Methodological caveats

Substantial methodological constraints complicate the interpretation of comparative health outcomes between CKM and dialysis. First, confounding by indication is pervasive, particularly as patients opting for CKM tend to be older, frailer, and have a higher baseline risk of mortality than those initiating dialysis. Second, many studies rely on cross-sectional designs, single-centre recruitment, or convenience sampling, thereby limiting internal validity and generalisability. Third, the absence of a standardised threshold for dialysis initiation and the lack of a clearly defined starting point for CKM contribute to lead-time and survival bias. This may differentially affect survival estimates in either treatment group. For example, anchoring survival to dialysis initiation may overestimate survival among dialysis patients by excluding individuals who die before treatment onset, whereas delayed or inconsistent definition of CKM initiation may similarly bias survival estimates among conservatively managed patients. Lastly, considerable heterogeneity in patient populations, outcome measures, and analytic approaches limits comparability across studies and hampers causal interpretation.

Taken together, the available evidence supports CKM as a clinically defensible and person-centred alternative to dialysis for selected patients. However, more methodologically rigorous and transparently designed studies are needed to more clearly delineate the net benefits and trade-offs between CKM and dialysis across diverse patient populations.

IDENTIFYING INDIVIDUALS WHO MAY BENEFIT FROM CONSERVATIVE KIDNEY MANAGEMENT

CKM is recommended for people with kidney failure for whom the benefits of kidney failure replacement therapy may not outweigh the associated risks and treatment burden [6]. Performing an individualized benefit–risk assessment, however, is challenging, particularly so in patients for whom kidney transplantation is not an option and given the absence of randomized comparisons between CKM and dialysis. Dialysis treatment is well known to impose substantial time demands, procedural burden, and risks of complications, including infections [40, 41]. Moreover, among patients who plan to initiate dialysis, an estimated 25% die before dialysis is actually started, highlighting the substantial vulnerability and competing risks present in this population. [42]. At the same time, dialysis is a life-prolonging treatment that can substantially alleviate symptom burden. Together, these considerations illustrate the clinical crossroads faced by people with kidney failure, who may have much to gain from dialysis but also much to lose in terms of treatment burden and complications, underscoring the need for careful weighing of the pros and cons of CKM and dialysis.

Risk prediction tools and clinical factors

Clinical guidelines suggest the use of risk prediction tools to help guide the choice between CKM and dialysis, including the Kidney Failure Risk Equation (KFRE), the Bansal 5-year mortality risk score, and the REIN score for death within 6 months of initiating dialysis [43]. However, the discriminatory ability of mortality risk scores to accurately predict death before dialysis, particularly in older and frail populations, has been questioned [44, 45].

In addition to life expectancy, other clinical factors that may tip the balance in favour of CKM rather than dialysis are highlighted in Table 3.

Table 3:

Considerations for deciding on conservative kidney management.

Patient preferences and quality of life considerations (time spent at home, time spent at clinic/hospital, procedural burden)

Family support

Frailty and ability to withstand dialysis complications

Comorbidities

Limited life expectancy

Cognitive impairment

Malnutrition, sarcopenia

CKM, conservative kidney management.

Comprehensive geriatric assessment

Apart from risk scores, guidelines suggest assessing frailty when helping guide people with kidney failure in their choice of treatment modality [43, 46, 47]. Evaluation of functional and cognitive capacities, as well as nutritional and psychosocial status, is not only important in terms of choosing the appropriate treatment, but also for identifying patients who require geriatric assessment or kidney supportive care [43]. Older people with kidney failure often experience functional dependency, multimorbidity, polypharmacy, cognitive deficits, and frailty. These factors, also referred to as geriatric syndromes, are prognostic for poor outcomes. For example, frailty is associated with an increased risk of hospitalisation and mortality, a higher symptom burden, and worse HR-QoL [48]. A recent meta-analysis concluded that the Clinical Frailty Score and the Fried Frailty Phenotype scale have acceptable discriminatory validity to predict mortality and hospitalisation in the kidney failure population [49]. Geriatric syndromes are therefore informative and provide a multidimensional approach to clinical decision-making surrounding CKM.

In geriatric medicine, a comprehensive geriatric assessment is used to assess and recognize patients’ vulnerabilities, aiming to prevent or delay complications. An extensive battery of tests, including cognitive, dietary, and physical evaluations, is performed [47]. Some authors have proposed adaptations of the extensive comprehensive geriatric assessment to create a briefer, nephrology-tailored test battery [50].

Evidence on whether comprehensive geriatric assessment leads to improved clinical outcomes in people with kidney failure is currently lacking. In oncology, however, the use of comprehensive geriatric assessment to support treatment decisions has been shown to improve HR-QoL, increase treatment completion, and lower treatment-related complications, unplanned hospital admissions, and caregiver burden [51–54]. These findings may be confirmed in kidney failure by an ongoing trial [55].

Until more evidence is accumulated, it seems prudent to screen for deficits in geriatric syndromes in older and frail patients to support a well-informed decision on CKM versus dialysis. Providing education to patients and caregivers with regards to the clinical importance of frailty for HR-QoL and prognosis, may also help set realistic expectations during the shared decision-making process, as well as help motivate lifestyle changes to prevent further decline [56].

WHEN TO INITIATE DISCUSSIONS ABOUT CHOOSING BETWEEN CKM AND DIALYSIS

The optimal timing to start conversations regarding CKM and dialysis remains uncertain. Ideally, patients should be informed sooner rather than later. Time is needed to reach a well-informed decision and, for patients opting for dialysis, time for access creation is also required. On the other hand, initiating these conversations well in advance of the need for kidney failure replacement therapy may impose an unnecessary burden on many patients and increase healthcare resource use.

International guidelines suggest various risk- or eGFR-based thresholds. For example, the KDIGO guidelines advise to initiate the decision process in patients with ≥40% risk of developing kidney failure within 2 years [46]. However, despite increased use of risk estimation tools, applying such absolute risks to individual patients remains difficult [57]. For older patients, the competing risk of death can outweigh the risk of progressing to the point of ever requiring kidney failure replacement therapy [58, 59]. In addition, kidney function declines more slowly in older patients [60]. It is therefore plausible that conversations on kidney failure replacement therapy in older patients can safely be postponed to lower eGFRs, without significantly increasing the proportion of acute dialysis initiations. However, evidence to support such practice is currently lacking. In one small study among patients managed with CKM, 93% of patients were satisfied with being counselled once their eGFR reached ≤20 ml/min/1.73 m² [61]. Ultimately, the timing of the decision process needs to be individualised. A pragmatic approach would be to ask the patient if they would rather discuss their options sooner or later. ‘Deciding not to decide yet’ is an often neglected but valuable option [62].

A time-limited trial of dialysis, lasting 1–3 months, is sometimes employed as a person-centred option for individuals who remain ambivalent about the choice between CKM and long-term dialysis [63, 64]. Such a trial allows evaluation of whether dialysis is tolerated and improves a person’s well-being. A potential drawback could be hesitancy to stop dialysis once the process has been initiated. Therefore, it is essential to make a structured plan and have an open discussion in advance with patients and their caregivers about the possibility of dialysis withdrawal.

It is important to recognize that preferences are likely to change over time, especially in older patients due to the likelihood of health deterioration [65, 66]. Therefore, it is important to reevaluate decisions in a timely manner to ensure that treatments continue to align with care goals and preferences of people with kidney failure. In conclusion, choosing a treatment option is an ongoing process rather than a singular decision. Figure 1 shows a schematic representation of this treatment-decision pathway for older people approaching kidney failure.

Figure 1:

Treatment decision pathway for older people approaching kidney failure. Abbreviations: CKM, conservative kidney management.

SHARED DECISION MAKING AND THE PERSPECTIVES OF DIFFERENT STAKEHOLDERS

It is important for clinicians to recognize that deciding between CKM and dialysis is an iterative shared decision-making process that involves multiple stakeholders, including people with kidney failure, their caregivers, and clinicians together with other health care workers involved in a multidisciplinary team. The experiences and perspectives of these stakeholders are outlined below. We also briefly examine gender-related and regional differences in treatment choices between CKM and dialysis.

Patient perspectives

A scoping review found that most people with kidney failure were satisfied with their choice for CKM and felt that the treatment choice had been their own [67]. Patients generally favoured open discussions with their physicians at an early stage about treatment options and prognosis [67, 68]. Although most patients were satisfied with the shared decision-making process, Dutch survey data indicates that negative experiences were not uncommon, including feeling pressured to start dialysis [61]. Moreover, people on dialysis more often experienced doubt about their treatment choice than people who opted for CKM [61]. Patient interviews further reveal that communication surrounding treatment choices remains, at times, suboptimal. Conversations may feel rushed and important information may be omitted or provided in an unclear or insensitive manner [69]. These findings emphasize the need to develop shared decision-making skills among current and future kidney healthcare professionals [70].

Caregiver perspective

Caregivers of people with kidney failure have an important supportive and influential role in deciding between CKM and dialysis, [67]. At the same time, multiple studies have demonstrated that caregiver burden is high and increases over time [71, 72]. One study demonstrated that HR-QoL was comparable between caregivers of people on dialysis with those of people managed with CKM, but that the care-related quality of life was worse among caregivers of people on dialysis [73]. Educational outreach and efforts to improve communication with caregivers, in addition to involving them more in the decision-making process, could perhaps help alleviate caregiver’s anxiety [74, 75].

Clinician perspective

There is a well-recognized disconnect between the priorities of people approaching kidney failure and those of their healthcare providers [76]. In one study, nephrology providers’ perceptions of their patients’ top health outcome priorities were only correct 35% of the time [77]. A Delphi study found that only one of the top 10 quality indicators deemed most important by people receiving CKM was present in the top 10 of healthcare professionals [78]. Similarly, people on dialysis are more likely to value symptom control and quality of end-of-life care, in contrast to health care providers who prioritize clinical end points, such as measurement of pain or other symptoms, and place of death [79]. These findings highlight the importance of thoroughly exploring patient´s priorities, simply by asking.

Gender differences in opting for conservative kidney management or dialysis

There is an observed skewness regarding how men and women opt for CKM or dialysis. In most available studies, men more often receive dialysis than CKM (Table 2). This may be explained by men having an overall more progressive course of CKD, being more likely to reach kidney failure, and therefore having a greater need for kidney failure replacement therapy [80]. Women, on the other hand, often reach kidney failure at a higher age, when CKM may be a more intuitive treatment pathway. Nevertheless, women are less likely to receive dialysis, even when compared to an age-matched cohort of men with kidney failure [81–83].

Several factors may contribute to gender differences in the treatment of kidney failure, including personal preferences and social circumstances. For instance, women may be more receptive to palliative approaches or more likely to live alone, potentially lacking caregiver support [84]. Moreover, women less often receive specialized nephrology care and clinicians may perceive older women as more frail and therefore less suitable for dialysis [85–87]. Outcomes may also be less favourable in women receiving dialysis treatment. Women have been shown to more often report symptoms, experience a lower HR-QoL, and exhibit higher hospitalisation rates than men, although overall survival among older women and men appears to be similar [81, 88–91]. Considering these gender differences, it is important to be mindful of potential biases when supporting patients in choosing their preferred treatment pathway.

Regional variability in implementation and potential cultural barriers

Large regional and cultural differences are present in the acceptability and implementation of CKM [92]. In Europe, the estimated proportion of patients receiving CKM ranges from 0% in Slovenia to 15% in Hungary [93]. In the Middle East and North Africa, 20% of people with kidney failure had not been offered CKM by their nephrologist [94]. Other key factors that have been identified to limit the implementation of CKM are a lack of training as well as financial, cultural, and religious barriers.

In their review on the impact of culture and religion on end-of-life care, O’Kelly et al. further describe how Western values can clash with other belief systems [95]. For instance, while patient autonomy is a cornerstone in Anglo-American culture, other cultural frameworks may prioritize family centered decision-making. These diverging values can be conflicting when managing diverse patient populations.

Decisions about whether to initiate or forgo dialysis are influenced by ethical and cultural beliefs, including whether patients are informed about their prognosis and whether dialysis is considered appropriate in those with limited life expectancy. An Australian interview found that caregivers may sometimes challenge patient’s autonomy and exert pressure on patients to undergo dialysis [96].

It is important that physicians acknowledge potential gaps between the beliefs of patients, their caregivers and their own beliefs. In this context, it may be beneficial to make use of professional interpreters or engage cultural liaisons. By doing so, physicians can tailor information to patients’ needs and overcome cultural barriers, although this remains challenging in clinical practice.

In summary, optimizing the decision-making process requires taking into consideration the perspectives of multiple different stakeholders. Additional steps necessary to increase the acceptance and uptake of CKM include educational initiatives aimed at both patients, caregivers, primary care physicians and nephrology trainees, as well as policy-level changes in resource allocation and reimbursement [64].

Decision aids

Discussing the different treatment options for kidney failure in a simple manner is complex, especially within the limited time-window provided by a clinic visit. Therefore, there is a growing recognition that better tools are needed to support patients, caregivers, and clinicians in shared decision-making. Decision aids may be one such helpful clinical tool. Decision aids are designed to support people with kidney failure, their caregivers and kidney healthcare professionals to identify health care problems at hand, reason about different views and experiences, discuss trade-offs and identify which treatment best suits the needs and priorities of the individual living with kidney failure [97, 98].

THE IMPORTANCE OF KIDNEY SUPPORTIVE CARE

Irrespective of choosing CKM or dialysis, older people with kidney failure often have health care needs that are best supported by implementing kidney supportive care. Kidney supportive care is a palliative care approach that is fully integrated with CKM and should be provided to dialysis patients whenever needed. Kidney supportive care constitutes a holistic approach that addresses physical, psychological, social, and spiritual health with the aim to prevent suffering and maintain optimal HR-QoL in patients and their caregivers [99].

Kidney supportive care is best provided by a multidisciplinary team, including nephrologists, nurses, paramedics, and other medical specialties [100]. The team composition is flexible, particularly during the end-of-life phase, during which general practitioners, community services, and palliative care professionals are often more involved [6]. The organization and availability of such teams may vary internationally, as some countries have well-established palliative care networks and others rely more on primary care.

Another prerequisite is the availability of advance care planning to ensure that care remains aligned with patients’ preferences. Planning for future care also involves anticipatory symptom management. This may be provided by using a crisis plan, a structured approach that prepares patients, their caregivers, and professionals for common symptoms or acute deterioration that may occur in the home setting [6, 101]. This includes knowing whom to contact, how to recognize worsening symptoms, and how these can be addressed early. Dialysis patients tend to have frequent interactions with their healthcare providers, simplifying early intervention in case of clinical deterioration. In the case of patients receiving CKM, these individuals often have limited routine hospital-based oversight, in which case a crisis plan supports timely intervention and may prevent unwanted hospitalisations [40, 102].

Crisis planning naturally overlaps with advance care planning, during which healthcare professionals, patients, and their caregivers discuss the desirability of hospital admission, possible treatment limitations, or advance directives, such as the preferred place of death. Clarifying these preferences helps to define what quality of life means to the patient and ensures that end-of-life decisions reflect their goals [103]. Because preferences evolve over time, care plans should be regularly revisited [104, 105].

Spiritual care is an important yet often overlooked aspect of palliative care. During end-of-life discussions, healthcare workers can engage patients in reflections on life, death, and meaning [106, 107]. Spiritual concerns can be explored simply by asking, ‘Are you at peace?’ [108]. Acknowledging patients’ spiritual needs should be standard in the holistic and person-centered approach to kidney failure treatment [47].

CLINICAL MANAGEMENT AND LIFESTYLE INTERVENTIONS IN CONSERVATIVE KIDNEY MANAGEMENT

For people with kidney failure opting for CKM, symptom management through both non-pharmacological and pharmacological appraoches, as well as lifestyle modifications focused on diet and physical activity, often play an important role in trying to maintain HR-QoL.

Lifestyle modifications require the help and coaching of a multidisciplinary team of nephrologists, primary care providers, nurses, dietitians, and physiotherapists, depending on the specific setting in which the person with kidney failure is receiving his or her care.

It is critical that the multidisciplinary kidney care team surrounding the patient feels confident to support them in these management approaches, which is why a clinical overview is provided below.

Symptom management

Older people with kidney failure managed with CKM may experience a range of unpleasant symptoms, including fatigue, pain, pruritus, insomnia, restless legs, leg swelling, dyspnoea, decreased appetite, nausea, and depression [10]. Although numerous scales are in use, the latest KDIGO 2024 guidelines specifically recommend using a validated tool to assess patient-reported outcomes, such as SF-36, RAND-65, PROMIS, and PROMIS-29 [46]. The abbreviated SF-12 is also commonly used, and the Dialysis Symptom Index (DSI) has also been validated and shown to be well-received by patients [109].

Since polypharmacy is a significant problem in the kidney failure population [110], non-pharmacological interventions should be used as an initial step whenever possible. A summary of suggestions for non-pharmacological and pharmacological treatment approaches for symptom-management is shown in Table 4, based upon recently published comprehensive reviews and guidance articles [111–113]. The International Society of Nephrology also provides a free online educational resource on symptom management in CKM [114].

Table 4:

Strategies for providing symptom relief in conservative kidney management.

Symptom	Assessment	First-line non-pharmacological treatment	Pharmacological treatment (if necessary)
Fatigue	Rule out contributing factors (anaemia, infection).	Physiotherapy, exercise [115].	Active anaemia management if considered a contributing factor (intravenous iron, ESA).
Volume overload	Physical examination of volume status.	Salt/fluid-restriction.	Loop diuretics, consider metalozone [116, 117].
Loss of appetite	Patient history and physical exam. Weight, height, BMI.Assess urea, albumin.Medication reconciliation and potential side effectsAssess constipation, possible bowel obstruction.	Dietary counselling.	Nutritional supplement drinks.
Nausea, vomiting	Patient history and physical exam.Medication reconciliation and potential side effectsAssess constipation, possible bowel obstruction.	Dietary counselling.	Consider deprescribing unnecessary medications which may contribute to nausea/vomiting.Antimimetics [46, 111].
Pain	Physical exam to assess underlying etiology and type of pain.Imaging if needed.Try to evaluate concomitant anxiety, depression, sleep disturbances.	Physiotherapy, exercise, massage/heat [46].	Acetaminophen (mild pain) or opioids (moderate-severe pain) according to World Health Organization ladder [46, 118–120].Low-dose gabapentin, TCA, SNRI for neuropathic pain [121].
Pruritus	Assess skin costume: dryness, excoriations, eczema, other skin lesions.	Emollients, UVB-light [46, 112].	Low-dose gabapentin [46, 112, 122]First-generation antihistamines may be used at night (sedating effects) [123].Dermatology-referral for skin conditions if needed.
Restless legs	Patient history.Assess iron status.Medication reconciliation and potential side effectsRule out other potential causes: evaluation of peripheral pulses, neurological exam.	Aerobic exercise, stretching, massage [124–126].	Iron supplementation.Discontinue potentially contributing medications.Low-dose gabapentin [124–126].Dopaminergic agonists (beware paradoxical symptom augmentation) [127].
Insomnia	Patient history to assess contributing factors (obstructive sleep apnea, pain, restless legs, anxiety, depression, dyspnea)	Sleep hygiene and management of contributing factors (sleep apnoea, pain, restless legs, anxiety, depression dyspnoea).Cognitive behavioural therapy, exercise, mindfulness [127].	Melatonin, non-benzodiazepine sedatives [46].
Depression, anxiety	Patient history.Use validated rating scales.	Exercise, CBT [128].	Initiate low-dose antidepressants.Refer to primary care or psychiatry if needed.

Table based on recommendations by Kalantar-Zadeh and colleagues [111], Fitzgerald et al. [112], the KDIGO 2024 CKD guidelines [46], the American Society of Nephrology Kidney Health Guidance on Conservative Management of people with Kidney Failure [113] and other specific references when listed.

Abbreviations: BMI, body-mass index; CBT, cognitive-behavioural therapy; ESA, erythropoetin stimulating agents; SNRI, serotonine-norepinephrine reuptake inhibitors; TCA, tricyclic antidepressants; UVB, ultraviolet B radiation.

It should be stressed that large-scale randomized control trials on managing specific symptoms in the kidney failure population are largely lacking. As a result, clinicians often apply treatments commonly effective in the general patient population or based on expert opinion, even though specific evidence of efficacy and safety in the kidney failure population may be absent. For instance, the quality of evidence underlying the use of melatonin and non-benzodiazepine sedatives for insomnia [127, 129], as well as the use of antidepressants [128, 130] in the kidney failure population remains low. As such, it is critical that prescribers make plans for follow-up and carefully evaluate any newly prescribed medications in their patients with CKM, and actively de-prescribe therapies that do not help their patients feel better.

Laboratory management

Mild electrolyte disturbances and metabolic derangements can often be tolerated by patients with CKM, whereas symptomatic or more severe laboratory abnormalities, especially involving potassium or calcium, should be addressed. Certain kidney protective medications may contribute to electrolyte disturbances, such as the use of renin-angiotensin-system inhibitors, however, down-titration or discontinuation of these is generally tied to worse health outcomes [131, 132], although it may sometimes be appropriate in late palliative stages.

DIETARY ADVICE IN CONSERVATIVE KIDNEY MANAGEMENT

Diet is an important element in CKM to mitigate uremic symptoms, metabolic derangements (e.g. metabolic acidosis and hyperkalaemia) and nutritional disturbances (e.g. malnutrition and sarcopenia). General benefits of low or very low protein diets for patients with CKD include a reduction in urea and acid generation, improvement in acid-base balance, bone mineral disease and in gut microbiota health [133, 134–137]. Part of these metabolic benefits are achieved from a reduction in protein intake, which leads to a lower influx of amino acids to the afferent arteriole of the glomerulus, preventing vasodilation, with a subsequent decrease in glomerular hyperfiltration [138], reduction of proteinuria [134, 139] and likely a slower CKD progression [136, 140].

When it comes to older frail people with kidney failure, the risks and benefits of implementing a low-protein diet need to be balanced and considered with caution according to the individual’s condition. Observational data from the EQUAL study, including patients 65 years and older with eGFR <20 ml/min/1.73 m² not on dialysis, suggests that protein restriction can be implemented safely in older people with kidney failure under careful monitoring of a specialised dietician, as long as enough energy intake is maintained [141]. However, frail older individuals with kidney failure are underrepresented in randomised controlled trials investigating the effects of low protein intake, highlighting the need for particular attention in this population. If malnutrition, sarcopenia or frailty is present, it is advisable to postpone or pause protein restriction, particularly if the kidney function is stable. On the other hand, in older patients with good nutritional status and advanced or rapidly progressive CKD, prioritising protein restriction is likely to be the best course of action [142]. In all cases, an individualised risk-benefit assessment is essential to guide the optimal dietary approach.

With that in mind, dietary advice must be tailored to account for age, sex, nutritional status, comorbidities, food preferences, and socioeconomic conditions [133]. Another important consideration is that not all people managed with CKM are willing to follow a restrictive protein diet. These people may instead benefit from dietary counselling on adjusting the protein intake to 0.8–1.0 g/kg/day, with food choices that adapt to their habits, preferences, and surroundings [133, 143].

Unnecessary potassium restriction should be avoided to allow the inclusion of nutrient-dense foods such as fruits, vegetables, legumes, nuts, and whole grains [144]. Dietary counselling should also emphasise food quality, generally prioritising minimally processed foods over ultra-processed foods, except for in late palliative stages, when the individual’s preferences should be prioritised [145].

Ultimately, the goal is to provide a dietary plan that is feasible, nutritionally adequate, and tailored to clinical and biochemical needs [143]. Continuous follow-up to monitor adherence and evaluate clinical outcomes is also key [143]. Figure 2 summarises approaches to dietary modification and the promotion of physical activity in older patients with CKM.

Figure 2:

Lifestyle modifications in kidney failure. Individualized dietary plan coupled with an individualized plan for increasing physical activity and decreasing prolonged periods of sedentary behavior are part of the treatment of people with kidney failure. The dietary plan should be tailored to the individual’s nutritional status, food habits, and socioeconomic conditions. A healthy dietary plan is to be prioritized, and special attention is to be given to avoid unneeded restrictions to healthy foods while limiting the intake of ultra-processed foods. On the physical activity and exercise side, the plan also needs to be individualized, and special attention is to be given for patients who are frail, who often have malnutrition and sarcopenia. Abbreviations: AA: amino acids; SSB: sugar-sweetened beverages. Created using Biorender.

PROMOTING PHYSICAL ACTIVITY

People managed with CKM are often sedentary [146, 147] and of old age, making them particularly vulnerable to sarcopenia [148]. Encouraging physical activity through either a structured exercise program or the promotion of spontaneous daily movement can help delay sarcopenia onset [149] and improve functional status [43]. For older patients with kidney failure it is important to propose a physical activity plan in line with the capacity of the individual, especially in case of frailty, along with strategies to minimize longer periods of sedentary behaviour. In fact, a scoping review of physical activity and sedentary behaviour interventions in older people with frailty and multiple health issues found positive results, although most studies did not focus on habitual physical activity or sedentary behaviour [150].

RESEARCH GAPS AND FUTURE DIRECTIONS

Although awareness of CKM has increased in recent years, significant knowledge gaps remain when it comes to optimising the decision pathway and determining the relative value of CKM versus dialysis for the individual patient. Ongoing studies include the DIALOGICA study, a prospective observational cohort of 1500 older patients with kidney failure comparing CKM and dialysis [151], and the PREPARE for Kidney Care trial in the UK, the first randomised controlled trial comparing CKM with dialysis in older adults with kidney failure. These studies will provide data on survival, HR-QoL, and treatment burden, and inform clinical guidelines. Several other key research questions remain unanswered, as listed in Table 5 below.

Table 5:

Prioritised areas of research in the field of conservative kidney management.

Optimising decision-making:   How can we as clinicians improve use of decision aids and facilitation of preference-sensitive discussions to better align with patients’ goals of care? How may the decision-making process differ in patients of different ethnic, socioeconomic, or religious backgrounds?

The use of artificial intelligence (AI):   Can AI be used to improve prognostication and gain insights into which individual patients might stand to benefit from CKM versus dialysis? Can AI be incorporated into daily clinical care to tailor medical information and improve patient education about CKM? Can new digital tools and AI be used to improve remote monitoring for people managed with CKM?

Gender disparities:   What are the factors underlying the greater proportion of men opting for CKM versus dialysis? Should sex-differences in how a treatment is experienced form the basis of specific recommendations for men and women with kidney failure? Are there gender disparities in the resources allocated to caring for CKM versus dialysis patients?

Symptom-management:   New safe and effective pharmacologies and non-pharmacological treatment strategies to improve management of common symptoms in people with kidney failure, including fatigue, pain, pruritus, restless legs, sleep disturbances, depression and anxiety. Difelikefalin, a kappa opioid receptor agonist, is currently only approved for the management of CKD-associated pruritus in haemodialysis patients [152], even though a phase 2 trial of non-dialysis patients found a roughly 20% reduction in itch-related quality-of-life measures [153]. A phase 3 trial in non-dialysis patients was terminated (NCT05342623). A large-scale trial of difelikefalin in CKM patients could be of value.

CONCLUSIONS

Although lack of evidence from randomised controlled trials and inherent differences between patients opting for CKM versus dialysis complicate objective comparisons between these two treatment options, evidence to date suggests that CKM should be viewed as a valid choice for carefully selected older patients, for whom the treatment burden of dialysis is unlikely to outweigh a potential longevity benefit. Careful consideration of pros and cons of each treatment pathway is essential, taking into account the perspectives of patients, caregivers and the clinician. Decision aids may be helpful to guide the shared decision-making process. Regardless of which treatment pathway is ultimately decided upon, the person with kidney failure should be supported by a multidisciplinary team skilled at providing kidney supportive care, a holistic palliative care approach that prioritises symptom-management and individual goals of care. Ongoing studies will hopefully provide further insights into how to optimise selection of CKM candidates, maximize HR-QoL for patients and guide clinicians in how to better align treatment goals with what truly matters to their patients.

CONFLICT OF INTEREST STATEMENT

K.B., P.B., C.M.A., J.M.W., S.H.J., F.W., C.J.J. have no relevant conflicts of interest related to the writing of this manuscript. Mv.O. is involved in the DIALysis or not: Outcomes in older kidney patients with GerIatriC Assessment (DIALOGICA) study.

FUNDING

K.B.’s research time for this manuscript was supported by the regional agreement between Karolinska Institutet and Region Stockholm (FOUU). F.W. is supported by FoU Region Västernorrland. J.J.C. is supported by the Swedish Research Council, the Swedish Heart and Lung Foundation, the Swedish Kidney Foundation, Westman Foundation and Region Stockholm (ALF Medicin).

DATA AVAILABILITY STATEMENT

No new data were generated or analysed in support of this research.