Comprehensive conservative care for kidney failure - The need for evidence-based guidance

Kidney failure is an increasing global health challenge.1Bikbov B. Purcell C.A. Levey A.S. et al.Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.The Lancet. 2020; 395: 709-733Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Whilst the precise global prevalence is unknown, there are estimates as high as 9.7 million affected people.2Himmelfarb J. Vanholder R. Mehrotra R. Tonelli M. The current and future landscape of dialysis.Nature Reviews Nephrology. 2020; 16: 573-585Crossref PubMed Scopus (0) Google Scholar In areas where there is access to care, a diagnosis of kidney failure generally connotes a lifetime of dialysis, as kidney transplantation is often not feasible. However not all patients are suitable for or desire to undergo kidney replacement therapy (KRT). There is evidence that dialysis may not prolong life and may significantly impair quality of life in some elderly multimorbid patients.2Himmelfarb J. Vanholder R. Mehrotra R. Tonelli M. The current and future landscape of dialysis.Nature Reviews Nephrology. 2020; 16: 573-585Crossref PubMed Scopus (0) Google Scholar,3Grubbs V. Tuot D.S. Powe N.R. O'Donoghue D. Chesla C.A. System-Level Barriers and Facilitators for Foregoing or Withdrawing Dialysis: A Qualitative Study of Nephrologists in the United States and England.American Journal of Kidney Diseases. 2017; 70: 602-610Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar For these patients, comprehensive conservative care might be an option. See supplement for definition and some challenges with the selection of comprehensive conservative care for kidney failure. The updated Kidney Disease: Improving Global Outcomes (KDIGO) guideline for the management of chronic kidney disease was recently published.4Stevens P.E. Ahmed S.B. Carrero J.J. et al.KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.Kidney international. 2024; 105: S117-S314Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar This new guideline encourages patient involvement in the decision-making process and urges HCPs to take a more individualised patient-centred approach to the management of kidney failure. Chapter 5 acknowledges comprehensive conservative care as an alternative to KRT. The chapter states that clinicians should inform and educate patients about KRT and comprehensive conservative care (Practice Point 5.5.1) and support comprehensive conservative management as an option for patients (Practice Point 5.5.2).4Stevens P.E. Ahmed S.B. Carrero J.J. et al.KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.Kidney international. 2024; 105: S117-S314Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar These are crucial recommendations for two reasons. First, whilst patients and their families/caregivers generally possess information about dialysis, they often lack the necessary level of information about comprehensive conservative care to make informed decisions.5Sakthivel P. Mostafa A. Aiyegbusi O.L. Factors that influence the selection of conservative management for end stage renal disease – a systematic review.Clinical Kidney Journal. 2023; (sfad269)PubMed Google Scholar Second, there is evidence that HCPs who view comprehensive conservative care as a last resort or 'non-treatment' may be reluctant to discuss it with patient and may urge patients to opt for dialysis despite patients' preferences and health status.5Sakthivel P. Mostafa A. Aiyegbusi O.L. Factors that influence the selection of conservative management for end stage renal disease – a systematic review.Clinical Kidney Journal. 2023; (sfad269)PubMed Google Scholar Whilst the new guideline recommends shared decision making, there is a need for more evidence-based recommendations specific to comprehensive conservative care to facilitate shared decision making. Stronger evidence from robust longitudinal studies is required to support the development of such recommendations. Continuous professional development courses that share the most current evidence to support comprehensive conservative care will enhance the uptake of any future recommendations. OLA declares personal fees from Gilead Sciences Ltd, Merck and GlaxoSmithKline (GSK) outside the submitted work and receives funding from the NIHR Birmingham Biomedical Research Centre (BRC), NIHR Applied Research Collaboration (ARC), West Midlands, NIHR Blood and Transplant Research Unit (BTRU) in Precision Transplant and Cellular Therapeutics at the University of Birmingham and University Hospitals Birmingham NHS Foundation, LifeArc, Innovate UK (part of UK Research and Innovation), Gilead Sciences Ltd, Merck, Anthony Nolan, GSK, and Sarcoma UK. Description of comprehensive conservative care Challenges with the selection of comprehensive conservative care Supplementary references Supplementary information is available at KI Report's website. Download .pdf (.12 MB) Help with pdf files