Rethinking Kidney Care: The Role of Conservative Kidney Management

Ms. M is an 85-year-old woman with type 2 diabetes, congestive heart failure (ejection fraction 25%), mild dementia, history of stroke, and peripheral vascular disease. She has recently been told that her kidney numbers are worsening, and her nephrologist said they need to plan for dialysis. She is unsure of starting dialysis, but her doctors didn’t give her another option.

Is there another option for Ms. M?

Enter conservative kidney management (CKM), a patient-centered treatment approach for people with chronic kidney disease (CKD) or end-stage kidney disease (ESKD) who choose to forgo dialysis. This pathway prioritizes quality of life, symptom management, and shared decision-making, often aligning with the goals and values of patients who may face significant burdens with dialysis (e.g., time on dialysis, infection risk, prolonged recovery time, frequent hospitalizations, worsening functional status) or have a limited life expectancy (i.e. those patients with serious illness or older age). Effective communication is at the heart of CKM, ensuring that patients and families understand the benefits, limitations, and realistic expectations of this approach.

In this blog, we will explore the CKM treatment plan, including how to identify good candidates, strategies for discussing it with patients, the role of shared decision-making, and prognostic factors in guiding these critical conversations.

CKM focuses on managing symptoms and slowing the progression of kidney disease without the use of dialysis or kidney transplantation. For patients with advanced CKD or ESKD, CKM emphasizes comfort, minimizing treatment burdens and supporting physical, emotional, and spiritual well-being. Key components of CKM include:

• Symptom Management: Addressing fatigue, nausea, itching (pruritus), and other symptoms related to advanced kidney disease.
• Nutritional Support: Tailoring dietary advice to promote well-being without the strict restrictions necessary for dialysis patients.
• Psychosocial and Emotional Support: Ensuring patients and families receive counseling and resources to cope with the emotional challenges of CKD.
• Advance Care Planning: Preparing for future health care needs, including end-of-life care.

Identifying candidates for CKM requires a nuanced understanding of patient-specific factors, including medical, psychosocial, and personal considerations. Some patients who may benefit from CKM include:

Older adults (>80) with significant comorbidities—such as severe heart failure, malnutrition, medically unstable (e.g., hypotension), advanced cancer, or dementia (inability to cooperate)—often have a limited life expectancy and may derive minimal survival benefit from dialysis. For these patients, CKM may better align with their preference to prioritize quality of life over intensive medical interventions, like dialysis.

Frailty is a key prognostic factor in CKD management. Dialysis can be physically taxing, and frail patients often experience declines in mobility, independence, and overall well-being after starting dialysis. CKM may be a more appropriate option for maintaining patients’ quality of life.

Studies show that dialysis does not significantly prolong survival in patients with an estimated life expectancy of less than six months. CKM allows these patients to focus on symptom control and meaningful experiences during their remaining time. Clinicians can use the Supportive and Palliative Care Indicators Tool (SPICT) to identify patients at risk across all care settings.

Some patients may prefer not to pursue dialysis because of its impact on lifestyle, the burden of frequent treatments, or concerns about potential complications. Respecting and supporting these preferences is key to patient-centered care.

A core tenet of palliative care, shared decision-making (SDM) is a collaborative process in which clinicians and patients work together to make health care decisions that align with the patient’s values, goals, and preferences. SDM around CKM is essential, because the decision to forgo dialysis involves weighing medical facts against deeply personal priorities.

In 2010, the Renal Physicians Association (RPA) released the second edition of its Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis (2nd Edition). Per the guideline, “Shared decision-making is the recognized preferred model for medical decision-making because it addresses the ethical need to fully inform patients about the risks and benefits of treatments, as well as the need to ensure that patients’ values and preferences play a prominent role.”

Begin by understanding the patient’s priorities. Are they focused on living longer, maintaining independence, or avoiding burdensome treatments? Open-ended questions such as, “What matters most to you in your care?” can help identify these goals.

Explain CKM as a valid and proactive approach, not merely the absence of dialysis. Use simple, non-technical language to outline what CKM entails, emphasizing its focus on comfort and quality of life.

Provide clear, evidence-based information about the patient’s prognosis with and without dialysis. Using validated prognostic models can guide these conversations. Communicating directly and empathically about “best case/worst case” scenario can be helpful. By using their responses, you will gain insight into their values to guide decision-making.

Encourage patients to express their thoughts, fears, and preferences regarding CKM and other treatment options. Active listening and empathetic responses can build trust and foster open dialogue. Reassure the patient and family that the care team will provide comprehensive support regardless of the chosen pathway.

Once a decision is made, ensure the patient feels empowered and respected in their choice.

Prognostic information is vital in helping patients make informed decisions about CKM. Clinicians should approach this aspect of communication with sensitivity, clarity, and an awareness of its emotional impact.

• Clinical Prognostic Models: Tools like the Kidney Failure Risk Equation or the Charlson Comorbidity Index can provide data-driven insights into survival probabilities with and without dialysis.
• Functional Assessments: Evaluating frailty, mobility, and overall health status can help contextualize prognostic discussions.
• Patient-Specific Factors: Consider age, comorbidities, and psychosocial circumstances when discussing prognosis.

• Use Visual Aids: Diagrams, graphs, or written summaries can make complex information more accessible.
• Frame Information in Context: Relate prognostic data to the patient’s goals. For example, discuss how CKM may support their desire for independence or time at home.
• Acknowledge Uncertainty: Be honest about the limitations of prognostic tools, emphasizing that they provide estimates rather than certainties.

Navigating challenges in CKM communication requires addressing emotional reactions with empathy, overcoming misconceptions by emphasizing CKM as a proactive choice, and managing family dynamics through facilitated discussions that prioritize the patient’s wishes.

Discussions about CKM can evoke fear, sadness, or even anger. Acknowledge these emotions with statements such as, “I understand this is a difficult decision, and it’s okay to feel this way.” Offer resources for counseling or support groups when needed.

Patients and families may perceive CKM as “giving up.” Reframe the conversation by emphasizing that CKM is an active, patient-centered choice aimed at maximizing quality of life.

Family members may have differing opinions about the best course of action. Facilitate family meetings to address concerns, ensure everyone feels heard, and focus on the patient’s wishes.

Communicating about conservative kidney management requires a thoughtful, patient-centered approach that integrates shared decision-making, honest discussions about prognosis, and compassionate support. By identifying appropriate candidates for CKM and engaging in open, empathetic conversations, clinicians can help patients make informed choices that honor their values and preferences.

CKM is not about withholding care but about providing the right care—care that prioritizes quality of life, respects patient autonomy, and aligns with individual goals. As health care providers, we have a responsibility to guide patients through these complex decisions with clarity, compassion, and unwavering support.

The below CAPC resources are helpful for clinicians looking for more information about kidney care (not specific to conservative kidney management):

• Nephrology Learning Pathway, which includes continuing education courses and other resources for clinicians who are working with patients who are living with kidney disease and/or end-stage kidney disease.
• Advances in Kidney Supportive Care: Communication Skills Training for Nephrology, a blog co-written by a palliative care clinician and nephrologist.
• Kidney Supportive Care: Expanding Choice with Concurrent Hospice and Dialysis Care, an on-demand case review about the role of concurrent hospice and dialysis care and its impact on person-centered care.

Sources have been integrated throughout this blog post where applicable. The below additional resources were also used to write this blog post.

• Active Medical Management Without Dialysis Pathway (Pathways Project). Coalition for Supportive Care of Kidney Patients, The George Washington University. Published 2019. Accessed February 10, 2025. https://www.kidneysupportivecare.org/node/146
• Brown M, Chou A, Li C, Farshid S, Hoffman A. Survival, symptoms and hospitalisation of older patients with advanced CKD managed without dialysis. Nephrology Dialysis Transplantation. 2022;38(2). https://doi.org/10.1093/ndt/gfac154
• Brown M, Chou A, Li C, Farshid S, Hoffman A. Survival, symptoms and hospitalisation of older patients with advanced CKD managed without dialysis. Nephrology Dialysis Transplantation. 2022;38(2). https://doi.org/10.1093/ndt/gfac154‌
• Verberne WR, Geers ABMT, Jellema WT, Vincent HH, van Delden JJM, Bos WJW. Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis. Clinical Journal of the American Society of Nephrology. 2016;11(4):633-640. https://doi.org/10.2215/cjn.07510715
• Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrology Dialysis Transplantation. 2010;26(5):1608-1614. https://doi.org/10.1093/ndt/gfq630
• Engelbrecht BL, Kristian MJ, Inge E, et al. Does conservative kidney management offer a quantity or quality of life benefit compared to dialysis? A systematic review. BMC Nephrology. 2021;22(1). https://doi.org/10.1186/s12882-021-02516-6

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.