What is the recommended conservative management approach for an older adult patient with Chronic Kidney Disease (CKD) Stage V, multiple comorbidities, and impaired renal function, who refuses renal replacement therapy?

Conservative Management of CKD Stage V Without Renal Replacement Therapy

For patients with CKD Stage V who refuse renal replacement therapy, comprehensive conservative kidney management (CKM) should be implemented as a structured, holistic care pathway that prioritizes quality of life through active symptom management, advance care planning, and multidisciplinary support. 1

Core Framework of Conservative Kidney Management

CKM represents planned, person-centered care that does not include dialysis but encompasses interventions to delay progression, minimize complications, and maximize health-related quality of life. 1 This approach is explicitly endorsed by KDIGO guidelines as an appropriate treatment option for patients who choose not to pursue renal replacement therapy. 1

Essential Components of the CKM Program

The comprehensive conservative management program must include the following elements:

1. Medical Management to Slow Progression and Prevent Complications

• Initiate SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin) in CKD Stage V patients not yet on dialysis to slow progression and reduce cardiovascular events 2
• Continue ACE inhibitors or ARBs if proteinuria is present, targeting ≥30% reduction in urinary albumin excretion, accepting transient creatinine increases up to 30% 2
• Prescribe statin or statin/ezetimibe combination for all patients ≥50 years with eGFR <60 mL/min/1.73 m² to reduce cardiovascular mortality 1, 2
• Target blood pressure <130/80 mmHg using ACE inhibitors/ARBs as first-line agents, particularly with proteinuria 3, 2
• Manage metabolic complications including hyperkalemia (dietary potassium restriction, potassium binders), metabolic acidosis (sodium bicarbonate if serum bicarbonate <22 mEq/L), hyperphosphatemia (phosphate binders), and anemia (erythropoiesis-stimulating agents targeting hemoglobin 10-11.5 g/dL) 4

2. Active Symptom Management Protocols

Establish specific protocols for managing uremic symptoms including:

• Pruritus: Gabapentin 100-300 mg post-dialysis equivalent dosing, topical emollients, UV phototherapy 1
• Nausea/vomiting: Ondansetron 4-8 mg (dose-adjusted for renal function), metoclopramide with caution 1
• Pain management: Acetaminophen as first-line; avoid NSAIDs; use opioids with extreme caution and dose adjustment (prefer fentanyl or methadone over morphine) 1
• Fluid overload: Loop diuretics at high doses (furosemide 160-240 mg daily or equivalent), dietary sodium restriction <2g/day 1

3. Advance Care Planning and Communication

All CKD programs must deliver structured advance care planning that includes:

• Document goals of care focusing on quality of life priorities, preferred location of death, and symptom burden tolerance 1
• Establish healthcare proxy and complete advance directives early in the disease course 1
• Discuss prognosis explicitly using validated tools to estimate survival and functional decline trajectories 1
• Revisit decisions regularly (every 3-6 months) as clinical status changes, acknowledging that patients can transition to dialysis if they change their mind 1

4. Psychological, Social, and Spiritual Support

Provide access to multidisciplinary team members including:

• Nephrology social workers for assistance with disability applications, transportation, housing, and caregiver support 1
• Palliative care specialists for complex symptom management and existential distress 1
• Chaplaincy or spiritual care tailored to patient's cultural and religious background 1
• Mental health professionals for depression screening (PHQ-9) and treatment, anxiety management 1

5. Coordinated End-of-Life Care

Establish clear pathways for terminal care that include:

• Hospice referral criteria: Median survival <6 months based on eGFR <10 mL/min/1.73 m² plus severe comorbidities, functional decline, or recurrent hospitalizations 1
• Location preferences: Home-based hospice, inpatient hospice facility, or hospital-based palliative care unit based on patient choice and symptom complexity 1
• Bereavement support for family members following culturally appropriate practices 1

Monitoring Strategy for CKM Patients

Implement structured surveillance with the following schedule:

• Monthly visits initially (first 3 months) to establish symptom control and medication optimization 3
• Every 3-6 months thereafter: Blood pressure, serum creatinine, eGFR, electrolytes (sodium, potassium, bicarbonate), complete blood count, calcium, phosphate, parathyroid hormone 3, 4
• Renal ultrasound every 6-12 months to assess for hydronephrosis or structural complications 3
• Functional status assessment at each visit using validated tools (Karnofsky Performance Status, ECOG) 5

Critical Implementation Barriers and Solutions

Despite guideline endorsement, CKM remains underutilized due to systemic barriers:

• Only 7% of eligible US patients pursue CKM, and only 18% report discussions about forgoing dialysis with their nephrologist 6
• Only 37% of nephrology clinics have written CKM protocols, and only 5% have dedicated personnel or teams responsible for CKM delivery 6, 7
• Terminology inconsistency creates confusion; use "conservative kidney management" rather than "non-dialysis care" or "palliative care" to avoid negative connotations 7, 5

To overcome these barriers:

• Designate a CKM coordinator (nurse practitioner, physician assistant, or specialized nurse) within the nephrology practice 6, 7
• Develop written protocols for symptom management, medication dosing, and advance care planning specific to your practice 6, 7
• Engage primary care providers early in advance planning and end-of-life care coordination 1

Prognostic Considerations

Survival with CKM varies widely based on age and comorbidity burden:

• Median survival ranges from 6-30 months for patients choosing CKM versus 8-67 months for those choosing dialysis 8
• In patients ≥75 years with diabetes, hypertension, or cardiovascular disease, the survival advantage of dialysis may be limited or absent, making CKM particularly appropriate 1, 8
• Functional status is the strongest predictor: Patients requiring assistance with transfers or having Karnofsky Performance Status <50 have median survival <12 months regardless of treatment choice 8, 5

When to Reconsider Dialysis Initiation

Patients may transition from CKM to dialysis if:

• Intractable uremic symptoms develop despite maximal medical management (severe nausea, encephalopathy, pericarditis) 1
• Patient changes their mind after experiencing the reality of conservative management 1
• Acute reversible decline occurs (e.g., prerenal azotemia from dehydration) where temporary dialysis may restore baseline function 1

Quality Metrics for CKM Programs

The highest priority quality indicator identified by patients and caregivers is "percentage of patients who die in their desired location," yet this often diverges from what healthcare professionals prioritize 5. Programs should track:

• Symptom burden scores using validated tools (Edmonton Symptom Assessment System adapted for renal patients) 5
• Advance directive completion rates (target >90%) 5
• Hospitalization rates in the last 30 days of life (lower is better, target <50%) 5
• Hospice enrollment at least 7 days before death (target >70%) 5