What Are Palliative Alternatives to Renal Replacement Therapy for People With Advanced Kidney Failure?

Introduction and Scope of the Problem

Questioning which patients with end-stage kidney disease should be offered dialysis dates to the early 1960s, when dialysis was first invented. At that time, ethical considerations pertained to the distribution of limited dialysis-related resources. However, for the past many decades, the near-universal availability of dialysis in high-income countries has allowed nephrologists to prescribe it for every patient in whom it might be indicated. This has resulted in a tremendous increase in frail patients who have multiple comorbidities starting chronic dialysis. Not every patient, however, derives equal benefit from dialysis, and clinical and ethical considerations have shifted to deciding whether maintenance dialysis is appropriate in terms of providing either a survival or a quality-of-life advantage. Patients who are unlikely to receive either a survival or a quality-of-life advantage with dialysis should be offered conservative (nondialytic) kidney management as an alternative.

Definition of Conservative Kidney Management

Conservative kidney management is a treatment option for patients with end-stage kidney disease (i.e., estimated glomerular filtration rate [eGFR] <15 mL/min/1.73 m ² ) for whom the burdens of dialysis outweigh the anticipated benefits and should be offered to all patients who may not benefit meaningfully from dialysis. Conservative kidney management, through shared decision making and holistic patient-centered care, emphasizes quality of life without pursuing dialysis or transplantation. The guiding principle in conservative kidney management is to align care with the patient's preferences to achieve their personal goals, which typically focus on improving symptoms to enhance quality of life. Interventions to delay progression of kidney disease and manage the complications of end-stage kidney disease may still play an important role in care, insofar as they help with achieving the patient's specific goals.

Conservative kidney management is distinct from choice-restricted conservative care, in which resource constraints limit access to dialysis, and from withdrawal of dialysis, which refers to discontinuation of maintenance dialysis.

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