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Conservative and supportive kidney care

TL;DR — Conservative kidney management is active treatment without maintenance dialysis: symptom control, complication management, advance care planning and support for patients and families. Comparative evidence is observational and selection-biased. A 2021 review found lower mortality with dialysis overall (pooled HR 0.47, 95% CI 0.34–0.65), but survival differences were ambiguous in people aged at least 80 or with heavy comorbidity, while quality-of-life and hospitalization outcomes sometimes favoured conservative care (Buur 2021, PMID 34507554). Across cohorts foregoing dialysis, median survival ranged 1–41 months and quality of life was often stable until late illness, but acute-care use varied widely (Wong 2022, PMID 35285915).

What conservative care is

It includes kidney-protective treatment when beneficial, anaemia and symptom management, dietary support, psychosocial care and planning; it is not abandonment.

Survival evidence

An earlier review identified 12 cohorts (11,515 patients) with median survival 8–67 months on dialysis versus 6–30 months on conservative management. Its pooled adjusted mortality HR of 0.53 (95% CI 0.30–0.91) favouring dialysis came from a subset of those studies — patients aged ≥65 with eGFR <15 mL/min/1.73 m² whose multivariable models included age and comorbidity — and significant heterogeneity precluded definitive conclusions (Wongrakpanich 2017, PMID 28538218).

Quality and treatment burden

Dialysis adds treatment time, transport, procedures and hospitalization; conservative care may preserve time at home for some high-comorbidity patients (Buur 2021, PMID 34507554).

Outcomes after foregoing dialysis

Forty-one cohorts reported median survival 1–41 months; 27–68% died in hospital and 12–71% at home, showing system-level variation (Wong 2022, PMID 35285915).

Decision quality

Present both pathways before crisis, include uncertainty and elicit goals. A predicted survival difference is not interchangeable with preferred lived time.

Evidence gap

A 2025 Cochrane review searched to 22 September 2025 and found no randomised controlled trials; it pooled 24 non-randomised studies (26,127 people). Death from any cause was more frequent with conservative management (23 studies, 24,628 participants: 813 versus 630 per 1,000; RR 1.28, 95% CI 1.17–1.41; I² = 89%), but every estimate was graded very-low certainty because prognostic imbalance could not be addressed, and no included study reported cardiovascular events, malnutrition, sarcopenia, residual kidney function or adverse events (Yang 2025, PMID 41363177).

Comparative evidence table

Review Evidence base Survival estimate Patient-important findings Main bias
Wongrakpanich 2017 12 cohorts; 11,515 patients Dialysis vs CKM adjusted HR 0.53 (0.30–0.91), from a ≥65/eGFR<15 subset only Median survival ranges 8–67 vs 6–30 months Heterogeneity and fitter dialysis group (PMID 28538218)
Buur 2021 25 observational studies Dialysis vs CKM pooled HR 0.47 (0.34–0.65) CKM sometimes favoured QoL/secondary outcomes Survival ambiguous ≥80/high comorbidity (PMID 34507554)
Wong 2022 41 CKM cohorts; 5,102 patients Median survival 1–41 months QoL often stable until late; 1–2 admissions/person-year No direct causal comparison (PMID 35285915)
Cochrane 2025 24 non-randomised studies; 26,127 people; no RCTs found Death RR 1.28 (1.17–1.41) with CKM; I² = 89% HRQoL differences small and imprecise (PCS −1.46, MCS −2.50) All outcomes very-low certainty; prognostic imbalance (PMID 41363177)

Comparing conservative care with dialysis: what the best cohort actually measured

Survival is the outcome most often quoted and least often the deciding one. In a single-centre Dutch cohort of 366 patients aged ≥70 with advanced CKD who chose dialysis (n = 240) or conservative care (n = 126) after multidisciplinary counselling, the overall survival advantage of the dialysis pathway diminished or lost significance in patients aged ≥80 or with severe comorbidity. Cross-sectional health-related quality of life measured with the KDQOL-SF showed no differences in physical or mental health summary scores between the two pathways (all p > 0.1). Patients on conservative care had 352.7 hospital-free days per year versus 282.7 on the dialysis pathway — an adjusted incidence rate ratio of 1.15 (95% CI 1.09–1.21; p < 0.001), or about ten extra weeks a year out of hospital. Annual treatment costs were lower with conservative care (adjusted cost ratio 0.43, 95% CI 0.28–0.67; p < 0.001) (Verberne 2018, PMID 30115028).

Three caveats belong with these numbers. Treatment was chosen, not randomized, so patients who chose conservative care differ systematically. Quality of life was measured cross-sectionally, which cannot capture trajectory or the period closest to death. And the setting is one well-resourced European centre with structured multidisciplinary counselling — the counselling itself is part of the intervention being described.

The finding that matters for shared decision-making is not the survival comparison but that the two groups reported comparable physical and mental health while differing by 70 hospital days a year. A conversation framed only around months of survival omits the outcome on which the pathways differ most.

Advance care planning: an intervention that has been tested

SPIRIT (Sharing Patients' Illness Representations to Increase Trust) was a cluster randomized trial across 42 dialysis clinics in five US states, enrolling 426 patient–surrogate dyads and following them up to 21 months or until patient death. The intervention was a single 45–60 minute facilitated discussion with a nurse practitioner, registered nurse or social worker, conducted in clinic or remotely (all remotely after March 2020), with a summary placed in the medical record. Primary two-week preparedness outcomes were dyad congruence on end-of-life goals of care, patient decisional conflict, surrogate decision-making confidence, and a composite of congruence and confidence; secondary outcomes were surrogate anxiety, depression and post-traumatic distress three months after patient death, with adjustment for the timing of assessment relative to the COVID-19 emergency declaration (Song 2024, PMID 38289604).

The design deserves attention independently of its result: it treats the surrogate's bereavement outcomes as endpoints, which is a defensible answer to the objection that advance care planning trials measure only documentation. A companion implementation analysis addresses whether the intervention can be delivered in routine dialysis clinics (Song 2025, PMID 39863263).

Outcome domain Conservative care vs dialysis pathway Source
Survival Advantage of dialysis diminishes or loses significance at age ≥80 or with severe comorbidity Verberne 2018, PMID 30115028
Physical and mental HRQOL No difference (all p > 0.1), measured cross-sectionally Verberne 2018, PMID 30115028
Hospital-free days per year 352.7 vs 282.7; adjusted IRR 1.15 (1.09–1.21) Verberne 2018, PMID 30115028
Annual treatment cost Adjusted cost ratio 0.43 (0.28–0.67) Verberne 2018, PMID 30115028
Preparedness for end-of-life decisions Testable by a single facilitated discussion; cluster RCT across 42 clinics Song 2024, PMID 38289604

Withdrawal from dialysis is a common mode of death, and palliative care reaches a minority

Among 1,226 incident haemodialysis patients at a US tertiary centre (2001–2013, deaths tracked to 2015), 536 died and 262 — 49% of deaths — followed withdrawal from dialysis. Risk factors for withdrawal before death were older age, white race, palliative care consultation within six months, hospitalisation within 30 days, cerebrovascular disease, and absence of coronary artery disease. Most withdrawal decisions were made by the patient (60%) or a family surrogate (33%), and the stated reasons were acute medical complications (51%) or failure to thrive and frailty (22%). Median time from withdrawal to death was 7 days (IQR 4–11). In-hospital death was less common in the withdrawal group (34% versus 46%; p = 0.003), and only 34% (90/262) of those who withdrew received palliative care services (Chen 2018, PMID 30026285).

Three implications follow for how this page frames conservative care. Withdrawal is not a rare event at the margin of dialysis practice — it precedes about half of deaths — so the conservative-versus-dialysis decision recurs throughout the treatment course rather than being made once. The 7-day median from withdrawal to death means the window for symptom planning is short and must be opened before the decision, not after. And a palliative care involvement rate of 34% among patients whose deaths were preceded by an explicit treatment-stopping decision is the concrete measure of the service gap.

The race gradient in withdrawal — more frequent in white patients — is reported consistently and its interpretation is unresolved: it may reflect differing preferences, differing communication, or differential access to the conversation.

Decision and interpretation matrix

Dimension Question Guardrail
Diagnostic axis Cause + G category + A category Avoid treating eGFR as the diagnosis
Time axis Chronicity and trajectory Separate acute change from persistent disease
Risk axis Kidney failure + cardiovascular events + death Show competing events
Treatment axis Eligibility, absolute benefit, harm, burden Do not rank drugs by relative effect alone
Measurement axis Assay, equation, repeatability State what was actually measured
Equity axis Testing, referral, access, affordability Audit downstream care, not labels only
Patient axis Symptoms, function, life participation Include outcomes patients prioritize
Evidence axis RCT, cohort, model, guideline Do not collapse designs

Evidence ledger

This ledger makes the page’s evidentiary mix inspectable. It does not imply that every source answers every question.

PMID Record used Role and boundary
34507554 Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? A systematic review. (Buur 2021, PMID 34507554) Synthesis; heterogeneity and included-study definitions constrain transport.
35285915 Long-term Outcomes Among Patients With Advanced Kidney Disease Who Forgo Maintenance Dialysis: A Systematic Review. (Wong 2022, PMID 35285915) Synthesis; heterogeneity and included-study definitions constrain transport.
28538218 Dialysis Therapy and Conservative Management of Advanced Chronic Kidney Disease in the Elderly: A Systematic Review. (Wongrakpanich 2017, PMID 28538218) Synthesis; heterogeneity and included-study definitions constrain transport.
41363177 Conservative kidney management versus dialysis for stage 5 chronic kidney disease in older people. (Yang 2025, PMID 41363177) Synthesis; heterogeneity and included-study definitions constrain transport.
38490803 KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. (KDIGO CKD Work Group 2024, PMID 38490803) Guideline or commentary; recommendation evidence depends on its review.
38519239 Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns. (Levin 2024, PMID 38519239) Guideline or commentary; recommendation evidence depends on its review.
32061315 Global, regional, and national burden of chronic kidney disease, 1990-2017. (GBD CKD Collaboration 2020, PMID 32061315) Modelled projection; the estimate follows from the model inputs and assumptions, not from observed randomized follow-up.
22038337 A population-based approach for the definition of chronic kidney disease: CKD Prognosis Consortium. (Cirillo 2012, PMID 22038337) Synthesis; heterogeneity and included-study definitions constrain transport.
23243116 Cohort profile: the chronic kidney disease prognosis consortium. (Matsushita 2013, PMID 23243116) Observational or conceptual evidence; association is not treatment effect.
37787795 Estimated GFR, Albuminuria, and Adverse Outcomes: individual-participant data meta-analysis. (CKD Prognosis Consortium 2023, PMID 37787795) Synthesis; heterogeneity and included-study definitions constrain transport.
30348535 Relationship of Estimated GFR and Albuminuria to Concurrent Laboratory Abnormalities. (Inker 2019, PMID 30348535) Synthesis; heterogeneity and included-study definitions constrain transport.
34554658 New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race. (Inker 2021, PMID 34554658) Observational or conceptual evidence; association is not treatment effect.
34563581 A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. (Delgado 2022, PMID 34563581) Guideline or commentary; recommendation evidence depends on its review.
26757465 Multinational assessment of equations predicting kidney failure. (Tangri 2016, PMID 26757465) Synthesis; heterogeneity and included-study definitions constrain transport.
20581422 A randomized, controlled trial of early versus late initiation of dialysis. (Cooper 2010, PMID 20581422) Intervention study; eligibility, comparator, endpoint and follow-up bound inference.
29729346 Validation of the IPOS-Renal Symptom Survey in Advanced Kidney Disease. (Raj 2018, PMID 29729346) Observational or conceptual evidence; association is not treatment effect.
31702883 A Phase 3 Trial of Difelikefalin in Hemodialysis Patients with Pruritus. (Fishbane 2020, PMID 31702883) Intervention study; eligibility, comparator, endpoint and follow-up bound inference.
37429259 Kidney Supportive Care for Working-Age Adults with Chronic Kidney Disease: symptom burden. (Liu 2024, PMID 37429259) Observational or conceptual evidence; association is not treatment effect.
31295050 A Descriptive Analysis of an Ambulatory Kidney Palliative Care Program. (Scherer 2020, PMID 31295050) Observational or conceptual evidence; association is not treatment effect.
37993776 Feasibility of Symptom monitoring WIth Feedback Trial for adults on hemodialysis. (Agarwal 2023, PMID 37993776) Intervention study; eligibility, comparator, endpoint and follow-up bound inference.
40599823 Fatigue across different chronic kidney disease populations: experiences and needs of patients. (Schade van Westrum 2025, PMID 40599823) Observational or conceptual evidence; association is not treatment effect.
32673242 Characteristics, Symptom Severity, and Experiences of Patients Reporting CKD in an Online Health Community. (James 2020, PMID 32673242) Observational or conceptual evidence; association is not treatment effect.
29551585 Establishing a Core Outcome Measure for Fatigue in Patients on Hemodialysis. (Ju 2018, PMID 29551585) Consensus or priority-setting exercise; it records participant judgement, not measured outcomes.
27497527 Establishing Core Outcome Domains in Hemodialysis: SONG-HD consensus workshop. (Tong 2017, PMID 27497527) Consensus or priority-setting exercise; it records participant judgement, not measured outcomes.
28238554 Developing a Set of Core Outcomes for Trials in Hemodialysis: International Delphi Survey. (Evangelidis 2017, PMID 28238554) Consensus or priority-setting exercise; it records participant judgement, not measured outcomes.
40569671 Core Outcome Measure for Life Participation in Patients with CKD. (Hughes 2025, PMID 40569671) Consensus or priority-setting exercise; it records participant judgement, not measured outcomes.

What can and cannot be concluded

  • Risk associations do not by themselves establish that changing the marker changes risk.
  • A relative effect must be paired with baseline risk, follow-up and the exact endpoint.
  • Albuminuria, acute eGFR change, chronic eGFR slope and kidney failure are not interchangeable.
  • Subgroup consistency is not evidence that every subgroup had adequate power.
  • Guideline recommendations combine evidence with values, feasibility, cost and service capacity.
  • Older adults require competing-mortality and treatment-burden framing.
  • Dialysis and transplantation comparisons are vulnerable to eligibility and immortal-time bias.
  • Modelled lifetime benefit is not a randomized observed benefit.
  • A biochemical response without a patient-important outcome remains a surrogate result.
  • This page is research synthesis, not individualized medical advice.

Research-design checklist

  • Define CKD cause, G category, A category and chronicity at baseline.
  • Report the creatinine or cystatin C equation and laboratory calibration.
  • Prespecify acute and chronic eGFR slopes when haemodynamic effects are expected.
  • Keep sustained GFR decline, kidney failure and replacement therapy separable.
  • Report absolute event risks, follow-up and confidence intervals with relative effects.
  • Treat death as a competing event where it can preclude kidney failure.
  • Measure hyperkalaemia, acute kidney injury and treatment discontinuation consistently.
  • Include symptoms, function, life participation and treatment burden.
  • Describe background RAS, SGLT2, MRA and GLP-1 therapy explicitly.
  • Prespecify albuminuria and cause strata without over-reading underpowered interactions.
  • Record screening, prescribing, persistence and monitoring as separate implementation steps.
  • Report representation, access and affordability variables needed for equity analysis.

Open questions

  • What is the causal effect of conservative management relative to dialysis in older adults? A 2025 Cochrane review found no randomised trials and graded all 24 non-randomised comparisons very-low certainty (Yang 2025, PMID 41363177) (Buur 2021, PMID 34507554). → OQ-7
  • Would a target-trial emulation with frailty, preference and longitudinal symptom data narrow the confounding that pooled hazard ratios cannot (Wongrakpanich 2017, PMID 28538218)?
  • Why does place of death vary from 27–68% in hospital and 12–71% at home across cohorts, and which system features explain it (Wong 2022, PMID 35285915)?

  • Which components of “conservative kidney management” are actually delivered? The label covers heterogeneous models that the comparative literature treats as one intervention (Yang 2025, PMID 41363177).

  • Is the comparable quality of life between conservative care and dialysis pathways (all p > 0.1) a real equivalence or an artefact of cross-sectional measurement that misses the trajectory nearest death (Verberne 2018, PMID 30115028)?

  • How much of the conservative-care result depends on structured multidisciplinary counselling being part of the pathway rather than on the pathway itself (Verberne 2018, PMID 30115028)?

  • Does advance care planning change what happens at the end of life, or only preparedness and surrogate bereavement outcomes (Song 2024, PMID 38289604) (Song 2025, PMID 39863263)?

  • Why does dialysis withdrawal occur more often in white patients, and does the gradient reflect preference, communication, or access to the conversation (Chen 2018, PMID 30026285)?

  • Why do only 34% of patients who withdraw from dialysis receive palliative care services, when withdrawal precedes 49% of deaths and median survival after it is 7 days (Chen 2018, PMID 30026285)?

References

  1. Buur et al. Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? A systematic review. BMC Nephrol. 2021;22(1):307. PMID 34507554
  2. Wong et al. Long-term Outcomes Among Patients With Advanced Kidney Disease Who Forgo Maintenance Dialysis: A Systematic Review. JAMA Netw Open. 2022;5(3):e222255. PMID 35285915
  3. Wongrakpanich et al. Dialysis Therapy and Conservative Management of Advanced Chronic Kidney Disease in the Elderly: A Systematic Review. Nephron. 2017;137(3):178-189. PMID 28538218
  4. Yang et al. Conservative kidney management versus dialysis for stage 5 chronic kidney disease in older people. Cochrane Database Syst Rev. 2025;12(12):CD015151. PMID 41363177
  5. KDIGO CKD Work Group et al. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314. PMID 38490803
  6. Levin et al. Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns. Kidney Int. 2024;105(4):684-701. PMID 38519239
  7. GBD CKD Collaboration et al. Global, regional, and national burden of chronic kidney disease, 1990-2017. Lancet. 2020;395(10225):709-733. PMID 32061315
  8. Cirillo et al. A population-based approach for the definition of chronic kidney disease: CKD Prognosis Consortium. J Nephrol. 2012;25(1):7-12. PMID 22038337
  9. Matsushita et al. Cohort profile: the chronic kidney disease prognosis consortium. Int J Epidemiol. 2013;42(6):1660-1668. PMID 23243116
  10. CKD Prognosis Consortium et al. Estimated GFR, Albuminuria, and Adverse Outcomes: individual-participant data meta-analysis. JAMA. 2023;330(13):1266-1277. PMID 37787795
  11. Inker et al. Relationship of Estimated GFR and Albuminuria to Concurrent Laboratory Abnormalities. Am J Kidney Dis. 2019;73(2):206-217. PMID 30348535
  12. Inker et al. New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race. N Engl J Med. 2021;385(19):1737-1749. PMID 34554658
  13. Delgado et al. A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. Am J Kidney Dis. 2022;79(2):268-288.e1. PMID 34563581
  14. Tangri et al. Multinational assessment of equations predicting kidney failure. JAMA. 2016;315(2):164-174. PMID 26757465
  15. Cooper et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609-619. PMID 20581422
  16. Raj et al. Validation of the IPOS-Renal Symptom Survey in Advanced Kidney Disease. J Pain Symptom Manage. 2018;56(2):281-287. PMID 29729346
  17. Fishbane et al. A Phase 3 Trial of Difelikefalin in Hemodialysis Patients with Pruritus. N Engl J Med. 2020;382(3):222-232. PMID 31702883
  18. Liu et al. Kidney Supportive Care for Working-Age Adults with Chronic Kidney Disease: symptom burden. Nephron. 2024;148(1):34-42. PMID 37429259
  19. Scherer et al. A Descriptive Analysis of an Ambulatory Kidney Palliative Care Program. J Palliat Med. 2020;23(2):259-263. PMID 31295050
  20. Agarwal et al. Feasibility of Symptom monitoring WIth Feedback Trial for adults on hemodialysis. BMC Nephrol. 2023;24(1):345. PMID 37993776
  21. Schade van Westrum et al. Fatigue across different chronic kidney disease populations: experiences and needs of patients. Clin Kidney J. 2025;18(5):sfaf118. PMID 40599823
  22. James et al. Characteristics, Symptom Severity, and Experiences of Patients Reporting CKD in an Online Health Community. J Med Internet Res. 2020;22(7):e18548. PMID 32673242
  23. Ju et al. Establishing a Core Outcome Measure for Fatigue in Patients on Hemodialysis. Am J Kidney Dis. 2018;72(1):104-112. PMID 29551585
  24. Tong et al. Establishing Core Outcome Domains in Hemodialysis: SONG-HD consensus workshop. Am J Kidney Dis. 2017;69(1):97-107. PMID 27497527
  25. Evangelidis et al. Developing a Set of Core Outcomes for Trials in Hemodialysis: International Delphi Survey. Am J Kidney Dis. 2017;70(4):464-475. PMID 28238554
  26. Hughes et al. Core Outcome Measure for Life Participation in Patients with CKD. Clin J Am Soc Nephrol. 2025;20(8):1041-1050. PMID 40569671
  27. Verberne WR, et al. Value-based evaluation of dialysis versus conservative care in older patients with advanced chronic kidney disease: a cohort study. BMC Nephrol. 2018;19(1):205. PMID 30115028
  28. Song MK, et al. Effectiveness of an Advance Care Planning Intervention in Adults Receiving Dialysis and Their Families: A Cluster Randomized Clinical Trial. JAMA Netw Open. 2024;7(1):e2351511. PMID 38289604
  29. Song MK, et al. Implementation of An Advance Care Planning Intervention in Dialysis Clinics. Am J Kidney Dis. 2025;85(6):679-686. PMID 39863263
  30. Chen JC, et al. End of Life, Withdrawal, and Palliative Care Utilization among Patients Receiving Maintenance Hemodialysis Therapy. Clin J Am Soc Nephrol. 2018;13(8):1172-1179. PMID 30026285