Conservative care in advanced chronic kidney disease

Abstract Increasing numbers of those with stage 5 chronic kidney disease are older, with multiple co-morbid conditions. There is growing awareness that, while dialysis may provide some survival advantage in this population, there is major disease and treatment burden associated with dialysis, and considerable impact on quality of life. Conservative (non-dialysis) management pathways are therefore increasingly being developed and studied, and more is known about the best ways to optimize quality of life for those managed without dialysis. In low- and middle-income countries, the resources for dialysis are frequently limited and conservative management is often imposed rather than chosen. However, in high-income countries, dialysis is more widely available, and the decision whether to follow a conservative management pathway or not needs to be carefully weighed. This will include the context of the ageing kidney, the overall prognosis, and the trajectory of illness, to inform the best individual decisions. Management of those following a conservative management pathway includes detailed communication and advance care planning, actively managing the kidney disease and minimizing complications, and detailed assessment and proactive management of symptoms.