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Kidney replacement therapy decisions

TL;DR — Dialysis should start for symptoms, refractory metabolic or volume problems, or inability to maintain health—not at an arbitrary eGFR. IDEAL found no survival advantage to planned early initiation (HR 1.04, 95% CI 0.83–1.30), and 76% of the late-start group began earlier than its target because clinical indications developed (Cooper 2010, PMID 20581422). Modality decisions compare in-centre haemodialysis, home haemodialysis, peritoneal dialysis, transplantation and conservative care through eligibility, life goals, support and local access. Transplant generally offers survival benefit to selected wait-listed patients, but comparisons are selection-sensitive (Geroldinger 2023, PMID 37403325). This page excludes dialysis engineering, access technique and immunosuppression protocols.

When to start

IDEAL randomized 828 adults to planned initiation at eGFR 10.0–14.0 versus 5.0–7.0 mL/min/1.73 m² (Cockcroft–Gault). Median time to initiation was 1.80 versus 7.40 months, and over median 3.59 years mortality was 37.6% versus 36.6% (HR 1.04, 95% CI 0.83–1.30); adverse-event frequencies did not differ (Cooper 2010, PMID 20581422).

What the crossover means

Symptoms and clinical indications drove many late-arm starts. The trial rejects eGFR-only early start, not responsive initiation when indications appear.

Modality choice

Home therapies trade autonomy and scheduling flexibility against training, space and caregiver burden. Observational survival comparisons are strongly confounded by eligibility and selection.

Transplant

Target-trial emulation of 4,408 waitlisted Austrian registry patients estimated a 2.22-year (95% CI 1.88–2.49) gain in 10-year restricted mean survival with transplantation, smaller in women (1.95 y) than men (2.35 y) because women survived longer on dialysis (Geroldinger 2023, PMID 37403325). A single-centre series of 33 octogenarian recipients versus 71 waitlisted controls reported HR 0.22 (0.11–0.45) for death after listing — a very small, highly selected sample rather than population-level evidence (Ravichandran 2020, PMID 32882090).

Preparation

Education, transplant evaluation and access planning should precede crisis initiation. KFRE can time preparation but does not dictate modality (Tangri 2016, PMID 26757465).

Explicit border

No dialysate composition, vascular-access procedure or immunosuppression protocol is catalogued here; those corpora are larger than CKD itself.

Decision comparison — not technique

The comparison keeps IDEAL timing evidence and the observational selection limits of modality and conservative-care cohorts visible (Cooper 2010, PMID 20581422; Buur 2021, PMID 34507554).

Pathway Potential advantages Main burdens/limits Evidence caution
In-centre haemodialysis Staff-delivered, scheduled treatment Travel, fixed time, post-dialysis symptoms Modality cohorts are selected
Home haemodialysis Scheduling autonomy, possible higher frequency Training, space, home support Intensive-dialysis data are heterogeneous (Mathew 2018, PMID 29348924)
Peritoneal dialysis Home-based, continuous therapy Daily workload, infection and membrane failure Comparative survival is confounded
Transplantation Freedom from dialysis and survival benefit in selected candidates Surgery, waiting, organ scarcity, lifelong immunosuppression Candidate selection drives comparisons (Geroldinger 2023, PMID 37403325)
Conservative kidney management Avoids dialysis workload; symptom- and goal-focused Shorter survival in many cohorts All direct comparisons are observational (Buur 2021, PMID 34507554)

Modality comparison: the numbers, and why they are fragile

Peritoneal versus haemodialysis has never been randomized at scale, and the observational answer depends heavily on where the survival clock starts. Matching 6,337 pairs from 98,875 US adults initiating dialysis in 2003, intention-to-treat survival from day 0 favoured peritoneal dialysis (HR 0.92, 95% CI 0.86–1.00; p = 0.04), with cumulative survival 85.8% versus 80.7% at 12 months (p < 0.01), 71.1% versus 68.0% at 24 months (p < 0.01), 58.1% versus 56.7% at 36 (p = 0.25) and 48.4% versus 47.3% at 48 (p = 0.50). The advantage was concentrated in those under 65, without cardiovascular disease and without diabetes. In a sensitivity analysis starting at 90 days, the overall difference disappeared (HR 1.05, 0.96–1.16), and haemodialysis was associated with better survival in the cardiovascular-disease and diabetes subgroups (Weinhandl 2010, PMID 20133483).

The reversal between the day-0 and day-90 analyses is the whole methodological problem in one dataset: early haemodialysis mortality includes catheter-start and crash-start events that are properties of unplanned initiation rather than of the modality, so the "modality effect" is substantially a preparation effect.

Dialysis intensity: more is not better

The Frequent Hemodialysis Network Nocturnal Trial randomized 87 patients to six-times-weekly nocturnal home haemodialysis or conventional thrice-weekly treatment. The nocturnal arm achieved 1.82-fold higher weekly stdKt/V(urea), 1.74-fold more treatments and 2.45-fold more weekly treatment time — a very large dose separation — yet neither co-primary outcome was met (death or LV mass HR 0.68; death or RAND Physical Health Composite HR 0.91). Phosphate and blood-pressure control improved; cognition, depression, nutrition and anaemia markers did not, and vascular access events trended higher (Rocco 2011, PMID 21775973).

Post-trial follow-up to a median 3.7 years found 14 deaths in the nocturnal arm versus 5 in the conventional arm, overall mortality HR 3.88 (95% CI 1.27–11.79; p = 0.01), and 3.06 (1.11–8.43; p = 0.03) in an as-treated analysis using a 12-month running treatment average — but 1.12 (0.44–3.22; p = 0.7) using a 6-month average. The authors attribute the signal partly to a surprisingly low conventional-arm mortality (0.03 deaths/patient-year), small sample and frequent prescription changes (Rocco 2015, PMID 25863828). This is a finding that should be reported rather than resolved: a large randomized dose increase produced no benefit and a mortality signal whose direction and magnitude depend on the analysis window.

Incremental initiation

A four-centre UK feasibility trial randomized 55 incident haemodialysis patients with urea clearance ≥3 mL/min/1.73 m² to incremental twice-weekly or standard thrice-weekly schedules for 12 months. About a third of screened patients were eligible and half of those agreed to randomization. There was no group difference in the slope of residual kidney function loss, and 92% of incremental versus 75% of standard patients retained urea clearance ≥2 mL/min/1.73 m² at six months. Serious adverse events were less frequent with incremental dialysis (IRR 0.47, 95% CI 0.27–0.81), serum bicarbonate was lower (suggesting a need for supplementation), deaths were three in each arm, and median costs were significantly lower (Vilar 2022, PMID 34418414). The trial was designed for feasibility and is not powered to establish either safety or residual-function preservation; its useful output is that only about one in six incident patients would enter such a trial.

Comparison Evidence Result Principal bias
PD vs HD, intention-to-treat from day 0 6,337 matched pairs (PMID 20133483) HR 0.92 (0.86–1.00) favouring PD Unplanned-start mortality attributed to modality
PD vs HD, from day 90 Same cohort HR 1.05 (0.96–1.16); HD better with CVD/diabetes Selection into modality by comorbidity
6×/week nocturnal vs 3×/week HD FHN Nocturnal, n=87 (PMID 21775973) Neither co-primary outcome met despite 2.45× treatment time Small sample; home-dialysis population
Same, long-term Post-trial follow-up (PMID 25863828) Mortality HR 3.88 (1.27–11.79); 1.12 (0.44–3.22) on 6-month as-treated Very low comparator mortality; prescription changes
Incremental vs standard initiation UK feasibility RCT, n=55 (PMID 34418414) No RKF slope difference; SAE IRR 0.47 (0.27–0.81); lower cost Feasibility design; ~1 in 6 incident patients eligible

Dialysis technique: one large positive result and one large null

Haemodiafiltration. Individual patient data meta-analysis of five randomized trials comparing online haemodiafiltration with standard haemodialysis (4,153 patients; 2,083 haemodiafiltration, 2,070 haemodialysis) found all-cause mortality in 477 (23.3%) versus 559 (27.0%) over median 30 months (IQR 24–36) — HR 0.84 (95% CI 0.74–0.95) — with no evidence of differential effect across prespecified subgroups and a graded relationship between convection volume and mortality risk (Vernooij 2024, PMID 39489903). The gradient is supportive but not independently randomized; achieved convection volume can still reflect treatment delivery and patient characteristics.

Cooler dialysate. MyTEMP was a pragmatic registry-based cluster-randomized trial in all eligible Ontario haemodialysis centres: 84 centres randomized 1:1 to personalised cooler dialysate (nurses setting dialysate 0.5–0.9 °C below each patient's pre-dialysis temperature, minimum 35.5 °C) or standard 36.5 °C for all, over four years covering 15,413 patients and about 4.3 million treatments. Mean dialysate temperature was 35.8 °C versus 36.4 °C. The primary composite of cardiovascular death or hospitalisation with myocardial infarction, ischaemic stroke or congestive heart failure occurred in 1,711/8,000 (21.4%) versus 1,658/7,413 (22.4%) — adjusted HR 1.00 (96% CI 0.89–1.11; p = 0.93). Even the mechanistic intermediate did not move: mean intradialytic systolic blood-pressure drop was 26.6 versus 27.1 mmHg (difference −0.5 mmHg, 99% CI −1.4 to 0.4; p = 0.14) (MyTEMP writing committee 2022, PMID 36343653).

MyTEMP is worth studying as a design as much as a result. A widely adopted practice, justified by a plausible haemodynamic mechanism and by small-trial surrogate data, was tested at whole-system scale and produced a hazard ratio of 1.00 with no effect on the intermediate that motivated it. One important limitation is that the achieved temperature separation was only 0.6 °C, smaller than in some protocols.

Technique change Design Result
Online haemodiafiltration vs haemodialysis IPD meta-analysis, 5 RCTs, 4,153 patients (PMID 39489903) All-cause mortality HR 0.84 (0.74–0.95); graded convection-volume dose–response
Personalised cooler dialysate vs 36.5 °C Cluster RCT, 84 centres, 15,413 patients, ~4.3 million treatments (PMID 36343653) Cardiovascular composite adjusted HR 1.00 (96% CI 0.89–1.11); intradialytic SBP drop unchanged

What the systematic reviews say about the two comparisons that matter most

Both of the modality questions patients ask most often have now been reviewed systematically, and both reviews report the same structural problem.

Peritoneal versus haemodialysis. A Cochrane review searching to June 2024 included 153 reports of 84 studies — 2 randomized trials and 82 non-randomised studies — evaluating PD versus HD in people initiating dialysis, with residual kidney function as the primary outcome and all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue as secondary outcomes. Studies varied widely in design (small single-centre through international registry analyses), in inclusion criteria and in treatment delivery (Ethier 2024, PMID 38899545).

Home versus in-centre haemodialysis. The updated Cochrane review, searching to October 2022 and adding non-randomised studies to the 2014 version, notes that few randomized trials have compared home haemodialysis with in-centre haemodialysis and that the relative benefits and harms remain uncertain, across an outcome set spanning cardiovascular and all-cause death, myocardial infarction, stroke, hospitalisation, vascular access interventions and infection, transplant waitlisting and receipt, quality of life, dialysis-related symptoms, fatigue, recovery time, cost-effectiveness, blood pressure and left ventricular mass (Cheetham 2024, PMID 38588450).

The randomized evidence for where dialysis happens and which modality is used remains sparse. The propensity-matched comparisons above should therefore be read as descriptions of practice rather than as randomized estimates of treatment effect.

Transplantation versus staying on the list: the size of the benefit, and its exceptions

The transplant-versus-dialysis comparison has not been randomized and randomization would generally be considered infeasible, so the question is what the observational evidence supports and where it does not. A systematic review searched to March 2021 and identified 48 observational studies and no randomized trials, covering 1,245,850 patients, all comparing all-cause mortality for transplantation versus dialysis in waitlisted patients — a design that partially controls for eligibility bias.

Of the 48 studies, 44 (92%) reported a long-term survival benefit of at least one year's duration associated with transplantation. But 11 of those same studies identified strata in which transplantation offered no statistically significant benefit over remaining on dialysis. Meta-analysis of the 18 studies suitable for pooling gave a hazard ratio of 0.45 (95% CI 0.39–0.54; p < 0.001), with significant heterogeneity persisting through subgroup, sensitivity and meta-regression analyses (Chaudhry 2022, PMID 35232772).

The pooled hazard ratio of 0.45 comes entirely from observational data with unresolved heterogeneity; waitlisting does not equalise the groups on factors that determine both transplantability and survival. Eleven studies reported strata without a statistically significant benefit, supporting individualised interpretation rather than treating the pooled association as universal.

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
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.
37403325 Sex differences in the survival benefit of kidney transplantation: target trial emulation. (Geroldinger 2023, PMID 37403325) Observational or conceptual evidence; association is not treatment effect.
32882090 Survival benefit of renal transplantation in octogenarians. (Ravichandran 2020, PMID 32882090) Observational or conceptual evidence; association is not treatment effect.
26757465 Multinational assessment of equations predicting kidney failure. (Tangri 2016, PMID 26757465) Synthesis; heterogeneity and included-study definitions constrain transport.
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.
29348924 Mortality and Hospitalizations in Intensive Dialysis: A Systematic Review and Meta-Analysis. (Mathew 2018, PMID 29348924) 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.
38291006 Survival of patients with kidney failure awaiting transplantation stratified by age and ethnicity. (Chaudhry 2024, PMID 38291006) Observational or conceptual evidence; association is not treatment effect.
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.
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.
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.
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.
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.
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.
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.
40712611 Global, regional, and national prevalence of kidney failure with replacement therapy and associated aetiologies, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. (GBD 2023 Kidney Failure with Replacement Therapy Collaborators 2025, PMID 40712611) Modelled projection; the estimate follows from the model inputs and assumptions, not from observed randomized follow-up.

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

  • Can structured preparation reduce crisis starts without moving dialysis earlier? IDEAL rejects eGFR-only early initiation, but symptoms drove 75.9% of its late-arm participants to start above target, so preparation and timing are separable questions (Cooper 2010, PMID 20581422). → OQ-10
  • What would a defensible modality comparison look like when every observational cohort is selected on eligibility and preference (Mathew 2018, PMID 29348924)?
  • How should the transplant survival benefit be presented to older candidates, given that the effect grows with age but rests on registry emulation rather than randomization (Geroldinger 2023, PMID 37403325)?

  • Should KFRE thresholds trigger preparation steps, and which ones? The equation predicts kidney failure; it does not indicate modality (Tangri 2016, PMID 26757465).

  • Does dialysis modality itself affect survival, or does the apparent PD advantage from day 0 (HR 0.92, 0.86–1.00) reflect unplanned haemodialysis starts, given that it disappears from day 90 (HR 1.05, 0.96–1.16) (Weinhandl 2010, PMID 20133483)?

  • Why did a 2.45-fold increase in weekly treatment time produce no benefit on either co-primary outcome, and a long-term mortality signal that depends on the analysis window (Rocco 2011, PMID 21775973) (Rocco 2015, PMID 25863828)?

  • Can incremental initiation be tested definitively when only about one in six incident haemodialysis patients is eligible and half of those consent (Vilar 2022, PMID 34418414)?

  • Is the haemodiafiltration mortality benefit (HR 0.84, 0.74–0.95) attributable to convection volume itself, and what convection volume is the minimum effective dose (Vernooij 2024, PMID 39489903)?

  • Was MyTEMP's null result a property of cooler dialysate or of a 0.6 °C achieved separation, and does any temperature protocol affect the intradialytic haemodynamics it was designed around (MyTEMP writing committee 2022, PMID 36343653)?

  • Why has the PD-versus-HD question generated 84 studies but only 2 randomized trials (Ethier 2024, PMID 38899545), and is a randomized modality comparison still feasible or ethical where both are available?

  • What would resolve the home-versus-in-centre haemodialysis question, given that few randomized trials exist and the outcome set spans mortality, access complications, transplant access, symptoms and cost (Cheetham 2024, PMID 38588450)?

  • Which patient strata lack a survival benefit from transplantation over remaining waitlisted? Eleven of 48 studies identified such strata but they have not been characterised consistently (Chaudhry 2022, PMID 35232772).

  • How much of the pooled hazard ratio of 0.45 (0.39–0.54) survives the residual selection that waitlisting does not remove, and what design short of randomisation could estimate it (Chaudhry 2022, PMID 35232772)?

References

  1. 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
  2. Geroldinger et al. Sex differences in the survival benefit of kidney transplantation: target trial emulation. Nephrol Dial Transplant. 2023;39(1):36-44. PMID 37403325
  3. Ravichandran et al. Survival benefit of renal transplantation in octogenarians. Clin Transplant. 2020;34(11):e14074. PMID 32882090
  4. Tangri et al. Multinational assessment of equations predicting kidney failure. JAMA. 2016;315(2):164-174. PMID 26757465
  5. 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
  6. Mathew et al. Mortality and Hospitalizations in Intensive Dialysis: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis. 2018;5:2054358117749531. PMID 29348924
  7. 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
  8. 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
  9. GBD CKD Collaboration et al. Global, regional, and national burden of chronic kidney disease, 1990-2017. Lancet. 2020;395(10225):709-733. PMID 32061315
  10. 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
  11. Matsushita et al. Cohort profile: the chronic kidney disease prognosis consortium. Int J Epidemiol. 2013;42(6):1660-1668. PMID 23243116
  12. CKD Prognosis Consortium et al. Estimated GFR, Albuminuria, and Adverse Outcomes: individual-participant data meta-analysis. JAMA. 2023;330(13):1266-1277. PMID 37787795
  13. Inker et al. Relationship of Estimated GFR and Albuminuria to Concurrent Laboratory Abnormalities. Am J Kidney Dis. 2019;73(2):206-217. PMID 30348535
  14. 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
  15. 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
  16. Chaudhry et al. Survival of patients with kidney failure awaiting transplantation stratified by age and ethnicity. Br J Surg. 2024;111(1). PMID 38291006
  17. 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
  18. 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
  19. 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
  20. 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
  21. Tong et al. Establishing Core Outcome Domains in Hemodialysis: SONG-HD consensus workshop. Am J Kidney Dis. 2017;69(1):97-107. PMID 27497527
  22. 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
  23. 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
  24. 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
  25. GBD 2023 Kidney Failure with Replacement Therapy Collaborators et al. Global, regional, and national prevalence of kidney failure with replacement therapy and associated aetiologies, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet Glob Health. 2025;13(8):e1378-e1395. PMID 40712611
  26. Weinhandl ED, et al. Propensity-matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010;21(3):499-506. PMID 20133483
  27. Rocco MV, et al. The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial. Kidney Int. 2011;80(10):1080-1091. PMID 21775973
  28. Rocco MV, et al. Long-term Effects of Frequent Nocturnal Hemodialysis on Mortality: The Frequent Hemodialysis Network (FHN) Nocturnal Trial. Am J Kidney Dis. 2015;66(3):459-468. PMID 25863828
  29. Vilar E, et al. A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function. Kidney Int. 2022;101(3):615-625. PMID 34418414
  30. Vernooij RWM, et al. Haemodiafiltration versus haemodialysis for kidney failure: an individual patient data meta-analysis of randomised controlled trials. Lancet. 2024. PMID 39489903
  31. MyTEMP writing committee. Personalised cooler dialysate for patients receiving maintenance haemodialysis (MyTEMP): a pragmatic, cluster-randomised trial. Lancet. 2022;400(10364):1693-1703. PMID 36343653
  32. Ethier I, et al. Peritoneal dialysis versus haemodialysis for people commencing dialysis. Cochrane Database Syst Rev. 2024;6(6):CD013800. PMID 38899545
  33. Cheetham MS, et al. Home versus in-centre haemodialysis for people with kidney failure. Cochrane Database Syst Rev. 2024;4(4):CD009535. PMID 38588450
  34. Chaudhry D, et al. Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list: systematic review and meta-analysis. BMJ. 2022;376:e068769. PMID 35232772