What is the approach to conservative kidney management for patients with advanced kidney disease who are not candidates for dialysis or transplantation?

Conservative Kidney Management for Advanced CKD

Conservative kidney management should be offered as a viable, quality treatment option for patients with advanced CKD who choose not to pursue dialysis or are unlikely to benefit from it, delivered through a comprehensive, multidisciplinary program that includes symptom management, advance care planning, and supportive care. 1

Who Should Be Offered Conservative Management

Patients over 75 years of age with high comorbidity burden and/or poor functional status should be strongly considered for conservative management, as the survival advantage of dialysis disappears in this population. 1

Conservative management is appropriate for:

• Patients who explicitly choose not to pursue renal replacement therapy after informed shared decision-making 1
• Patients medically advised against dialysis due to limited survival or quality of life benefit 1
• Elderly patients with multiple comorbidities where dialysis offers marginal or no survival advantage 1
• Patients with poor functional status requiring assistance with transfers 2

Critical distinction: Dialysis should be framed explicitly as a treatment choice, not the default therapy, for patients unlikely to benefit. 1

Core Components of Comprehensive Conservative Care

The KDIGO Controversies Conference defines comprehensive conservative care as planned holistic patient-centered care that must include: 1

Medical Management

• Interventions to delay CKD progression: ACE inhibitors/ARBs for proteinuria, blood pressure control to target <130/80 mmHg, avoidance of nephrotoxins (NSAIDs), dose adjustment of renally-cleared medications 3
• Metabolic management: Phosphate binders with meals, protein restriction to 0.6-0.8 g/kg/day to reduce uremic toxin generation, sodium restriction <2g/day 4, 5
• Cardiovascular risk reduction: This is paramount as most CKD patients die from cardiovascular causes, not kidney failure 3

Symptom Management

• Active symptom assessment using validated tools should be routine, addressing pain, fatigue, anorexia, pruritus, nausea, and anxiety/depression 1, 5
• Palliative care involvement for refractory symptoms, as dialysis has variable effects on symptom amelioration 5
• Management of uremic complications (metabolic acidosis, volume overload, electrolyte abnormalities) with medical therapy rather than dialysis 1

Communication and Decision Support

• Shared decision-making with detailed discussions about prognosis, treatment options, and patient values 1
• Advance care planning including goals of care, preferred location of death, and resuscitation preferences 1
• Decision aids may facilitate these discussions, though specific tools for CKD conservative management are limited 1

Psychosocial Support

• Psychological counseling for patients and families 1
• Social support coordination 1
• Spiritual care sensitive to cultural norms and individual beliefs 1

Multidisciplinary Team Structure

A multiprofessional team should deliver conservative care, ideally including: 1

Core team members:

• Nephrologist with conservative care expertise 1
• Nephrology nurse 1
• Dietician for nutritional counseling 1
• Social worker or psychologist 1

Extended team access:

• Palliative care specialists for symptom management and end-of-life planning 1
• Primary care physicians for community-based care coordination 1
• Chaplain for spiritual support 1

Implementation challenge: In the United States, no clinics in the CKDopps study had dedicated conservative management protocols or clinics, despite provider comfort with discussing this option. 2

Evidence on Outcomes

Survival

• For patients >75 years with high comorbidity and poor functional status, dialysis offers no survival advantage over conservative management. 1
• Observational studies (randomized trials are ethically challenging) show equivalent or better survival with conservative care in this specific population 1

Quality of Life and Symptom Burden

• Hospitalization rates are reduced and home death rates increased with comprehensive conservative care compared to dialysis. 1
• Limited data suggest equivalent to more favorable quality of life trajectories with conservative management versus dialysis in elderly, multimorbid patients 6, 7
• Symptom experiences may be compatible between conservative care and dialysis patients 7

When to Refer for Conservative Management Planning

Timely referral should occur when the risk of kidney failure within 1 year is 10-20% or higher, using validated risk prediction tools. 1

Specific triggers for discussion:

• eGFR <20 mL/min/1.73 m² with progressive decline over 6-12 months 1
• Development of uremic symptoms (though dialysis initiation should not be based solely on eGFR thresholds) 1
• Patient age >75 years with significant comorbidities 1

Common Pitfalls to Avoid

Never present dialysis as the only option or default therapy for advanced CKD. Comprehensive conservative care must be offered alongside dialysis and transplantation as equal treatment choices. 1

Do not equate conservative management with "doing nothing." This is active medical management requiring dedicated resources, protocols, and expertise. 1

Avoid delaying conservative care discussions until crisis. Early advance care planning when eGFR <30 mL/min/1.73 m² allows informed decision-making before urgent situations arise. 1

Do not assume all patients want maximum life prolongation. Patient values regarding quality versus quantity of life must guide treatment decisions through shared decision-making. 1

Current Practice Gaps in the United States

Only 7% of US patients with eGFR ≤30 mL/min/1.73 m² were planning for conservative management, and only 18% reported discussions about forgoing dialysis with their nephrologist. 2

Despite provider comfort discussing conservative management, systemic barriers include:

• No dedicated conservative management clinics or protocols 2
• Uneven access to palliative care services 1
• Poor reimbursement for cognitive services and advance care planning 1
• Minimal nephrology training in supportive care and communication skills 1

These gaps represent urgent targets for health system improvement to ensure equitable access to conservative management as a treatment option. 1, 2