Kidney failure planning and conservative care

01Purpose and principlesWhat the treatment does and how it fits into care.

Kidney failure planning is a longitudinal process rather than a single consent conversation. The renal multidisciplinary team should explain what each pathway involves in practical terms: likely schedules, vascular or peritoneal access, training, travel, recovery time, medicine burden, effects on work and caring roles, and the possibility of switching modality. Prognostic estimates can frame uncertainty but cannot decide whether a particular life is worth a particular treatment.

Pre-emptive kidney transplantation generally offers the best kidney-replacement outcome for suitable people and should be explored before dialysis is necessary, including the possibility of living donation. For those choosing haemodialysis or peritoneal dialysis, timely access planning avoids avoidable temporary central venous catheters and permits home assessment and training. The rate of eGFR loss, symptoms and access lead time matter more than a rigid calendar date.

Comprehensive conservative care is appropriate when it accords with an informed choice, including when dialysis is unlikely to provide benefits that outweigh its burdens. Care continues through renal, primary-care, geriatric and palliative teams, with active treatment of anaemia, oedema, itch, nausea, pain, breathlessness, anxiety and family needs. A person may reconsider dialysis, and a person receiving dialysis may later consider withdrawal; capacity, voluntariness and reversible distress must be addressed each time.

Key points

Begin kidney-failure education early enough for reflection, family involvement, transplant assessment and elective access creation; a crisis admission is a poor setting for first hearing the options.
Offer balanced information about transplantation, home or in-centre dialysis and comprehensive conservative management, including likely treatment burden, uncertainty and effects on everyday life.
NICE advises considering preparation for renal replacement therapy or conservative management at least one year before therapy is likely to be needed, allowing for individual progression and clinical judgement.
Start dialysis because symptoms, biochemical disturbance or uncontrollable fluid overload require it, or around an eGFR of 5 to 7 mL/min/1.73 m² when there are no symptoms; never use one higher eGFR threshold automatically.
Conservative management is active multidisciplinary kidney care without dialysis: it includes control of CKD complications, symptom treatment, psychological and social support, advance care planning and end-of-life care when appropriate.
Decision-making must be shared and revisited because frailty, cognition, transplant eligibility, home support, goals and the balance between benefit and burden can change.
Record the person's preferred modality, acceptable alternatives, escalation limits, resuscitation discussion where relevant and who should be contacted if deterioration occurs.
A decision not to dialyse does not mean withholding antibiotics, transfusion, diuresis, analgesia, nutrition support or hospital care unless these are also outside the person's agreed goals.
Pulmonary oedema, refractory hyperkalaemia, severe acidosis, uraemic pericarditis or encephalopathy still require urgent renal assessment even when a conservative pathway is being considered.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Approaching kidney failure

Falling eGFR, rising Kidney Failure Risk Equation estimate, worsening albuminuria or accumulating complications signals the need to move from surveillance to pathway preparation.

Symptom burden

Anorexia, nausea, pruritus, sleep disturbance, restless legs, reduced cognition, fatigue and breathlessness may reflect uraemia but have competing and treatable causes.

Treatment vulnerability

Severe frailty, recurrent admissions, advanced dementia, multimorbidity and limited functional reserve may increase dialysis burden without automatically excluding a time-limited or long-term trial.

Home feasibility

Housing, water and electricity, dexterity, vision, cognition, infection practice and available assistance shape home therapy delivery but should prompt support assessment rather than assumptions.

Changing priorities

A shift from longevity towards comfort, avoiding hospital, remaining at home or attending a family event should lead to a documented review of the treatment plan.

Last-days pattern

Increasing somnolence, minimal intake, profound weakness and reduced urine can accompany dying with kidney failure, but infection, hypercalcaemia, medicine toxicity and retention remain reversible differentials.

Red flags requiring action

Severe breathlessness with hypoxaemia or pulmonary oedema needs same-day emergency assessment and may require urgent ultrafiltration or dialysis despite previous stable planning.
ECG-toxic hyperkalaemia, progressive weakness or a rapidly rising potassium requires immediate cardiac protection and a renal removal strategy.
New confusion, seizure, pericarditic pain, bleeding tendency or persistent vomiting can represent advanced uraemia and should trigger urgent renal review.
A statement requesting treatment withdrawal during untreated depression, delirium, coercion or uncontrolled symptoms requires prompt capacity, safeguarding and reversible-cause assessment.
Sudden loss of an agreed home-care package or carer exhaustion can make an otherwise sound plan unsafe and warrants urgent multidisciplinary coordination.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Serial renal profile and trajectoryFirst step
Why
Estimate the pace of kidney failure and identify urgent biochemical indications for treatment.
Interpretation and limitations
Use repeated eGFR, potassium and bicarbonate alongside illness context; an acute decline may be reversible and does not define the long-term modality.
02
Kidney Failure Risk Equation
Why
Support timing of education, access discussion and specialist follow-up in an appropriate CKD population.
Interpretation and limitations
A calculated probability complements rather than replaces trajectory, competing mortality, cause of CKD and the person's goals; do not use it during unstable AKI.
03
Structured symptom assessment
Why
Find uraemic and palliative symptoms that need treatment and provide a baseline for review.
Interpretation and limitations
Severity, distress and functional impact are more useful than simply counting symptoms; constipation, infection, heart failure and adverse medicines may be modifiable.
04
Frailty and functional review
Why
Identify rehabilitation, falls, nutrition, cognition and care needs relevant to treatment burden.
Interpretation and limitations
Frailty supports a more individualised discussion but is not a stand-alone rule against dialysis or transplantation.
05
Access and transplant work-up
Why
Determine whether pre-emptive transplantation, fistula formation or peritoneal catheter placement is feasible in time.
Interpretation and limitations
Cardiovascular, vascular, abdominal and immunological assessments are pathway-specific and should follow the receiving centre's protocol.
06
Advance care planning reviewPreferred
Why
Confirm capacity, understanding, proxy decision-makers, escalation preferences and preferred place of care.
Interpretation and limitations
An advance decision applies only to the circumstances it validly covers; current capacitous wishes take precedence and plans require accessible documentation.

04Treatment approachPreparation, options, escalation and aftercare.

01PREPAREProgressive advanced CKDFirst stepRisk and trajectory suggest kidney replacement therapy or conservative care may be needed within the planning horizon.

1Arrange multidisciplinary education using accessible language, interpreters and decision support, inviting family or carers if the person wishes.
2Compare transplantation, each dialysis setting and comprehensive conservative care using individual comorbidity, likely burden and personally meaningful outcomes.
3Assess transplant eligibility and living-donor possibilities while evaluating vascular access, abdominal suitability, home circumstances and support needs.
4PreferredDocument a preferred pathway and contingency option, then review after clinical change rather than treating the first choice as irrevocable.

02STARTPossible dialysis initiationAdvanced kidney disease is accompanied by symptoms, resistant biochemical disturbance or uncontrollable fluid overload.

1Confirm that the problem is attributable to kidney failure and treat reversible contributors such as infection, obstruction, nephrotoxins, dehydration or medication effects.
2Discuss urgency with nephrology and assess potassium, acid-base status, volume, nutrition, cognition and pericardial or bleeding manifestations.
3Begin the agreed modality when clinical indications outweigh burden; use an urgent temporary route only when planned access cannot safely wait.
4After an unplanned start, revisit education and home or transplant options once the person is stable rather than allowing crisis modality to become the default forever.

03CONSERVEComprehensive conservative managementThe informed person chooses kidney care without dialysis, or dialysis burdens are judged unlikely to meet their goals.

1Agree which disease-modifying, complication and hospital treatments remain wanted, and explicitly correct any misunderstanding that conservative care means abandonment.
2Create a symptom plan for oedema, pain, itch, nausea, agitation and breathlessness with renal-safe prescribing and anticipatory access to specialist advice.
3EscalationCoordinate renal, general practice, community nursing, geriatrics and palliative care, naming a lead clinician and an out-of-hours escalation route.
4PreferredReview goals, capacity, family support and preferred place of care regularly, updating emergency records and anticipatory medicines as decline evolves.

04REVIEWWithdrawal or changed choiceA person receiving dialysis asks to stop, cannot tolerate treatment or no longer experiences acceptable benefit.

1Explore the request privately and compassionately, treating pain, delirium, depression, transport difficulty, conflict and dialysis complications that may be reversible.
2Confirm decision-making capacity and informed understanding, involving advocates, interpreters, family or legal proxies within the person's consent and applicable law.
3Consider treatment modification or a defined trial if this matches the person's priorities, while respecting a sustained capacitous refusal of dialysis.
4If withdrawal is chosen, transfer seamlessly to active symptom control, anticipatory prescribing, family support and a documented place-of-care plan.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Relieve oedema and breathlessness while meaningful kidney urine production remains, including during conservative management.

Loop diuretic for residual diuresis

Select and titrate an oral or parenteral renal regimen with specialist input according to urine output and congestion.

Monitor postural symptoms, sodium, potassium, blood pressure and dehydration; anuria will not respond and subcutaneous administration is a specialist palliative intervention.

Treat opioid-responsive pain or refractory breathlessness when non-drug and cause-directed measures are insufficient.

Renally appropriate opioid

Choose the agent, route and low starting dose from the local renal palliative protocol, then titrate to response.

Morphine and codeine metabolites accumulate in severe renal failure; sedation, myoclonus and respiratory depression require review, and conversion to alfentanil or another option needs specialist calculation.

Control uraemic or medicine-related nausea while constipation, gastric stasis, hypercalcaemia and obstruction are assessed.

Antiemetic selected by mechanism

Use the lowest effective renal-compatible dose from local palliative guidance, adjusted for frailty and intended route.

Haloperidol, levomepromazine, metoclopramide and cyclizine have different QT, anticholinergic and extrapyramidal risks; avoid stacking agents without a mechanism-based review.

Provide rapid relief of pain, agitation, respiratory secretions, nausea or breathlessness when oral treatment is no longer reliable.

Anticipatory symptom medicines

Prescribe individualised subcutaneous rescue and infusion doses under the regional end-of-life renal guideline before crises occur.

This is not a generic bundle: kidney clearance, previous exposure, frailty and syringe-pump compatibility must be checked by palliative or renal pharmacy specialists.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

Review symptoms, function, nutrition, cognition, volume status and carer strain at a frequency driven by trajectory rather than a fixed eGFR interval.
Track potassium, bicarbonate, haemoglobin and other CKD complications only when results will alter wanted treatment; avoid burdensome testing during the last days of life.
Reassess transplant status and access readiness as kidney-failure risk rises, because missed lead time can convert an elective plan into catheter-dependent emergency dialysis.
After any symptom-medicine change, check alertness, falls, constipation, nausea and myoclonus as well as benefit, with faster review after opioids or sedatives.
Record weight, breathlessness, oedema, blood pressure and urine output when diuretics or fluid advice are being adjusted.
Ask directly whether the current pathway still supports what matters to the person and whether family members understand whom to contact during deterioration.
Keep shared electronic and paper plans aligned across ambulance, out-of-hours, hospital and community services so unwanted transfers are less likely.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Planning begins before symptoms

Access formation and transplant assessment need lead time, whereas uraemic symptoms may appear only after the safe elective window has narrowed.

Conservative means comprehensive

It contains active renal and supportive treatment, not merely the omission of a dialysis machine.

Choice can legitimately change

Experience of illness, dialysis or family circumstances supplies new information and should prompt review without framing reconsideration as failure.

eGFR is not a start button

Clinical indications and the person's goals drive initiation; filtration estimates at very low levels are themselves imprecise.

A time-limited trial needs endpoints

Specify what improvement would justify continuation, what burden would prompt stopping and when the multidisciplinary review will occur.

Communication prevents crisis default

A clear contingency plan helps emergency clinicians distinguish wanted reversible treatment from escalation that contradicts established priorities.

08Common pitfallsFrequent interpretation and management errors.

01
Do not postpone all modality discussion until eGFR is extremely low or symptoms force an emergency admission.
02
Do not present conservative management as doing nothing, or dialysis as an obligation rather than a treatment requiring consent.
03
Do not promise an exact survival difference from population data without discussing frailty, uncertainty and outcomes other than longevity.
04
Do not assume advanced age or disability rules out home dialysis or transplantation before appropriate specialist assessment.
05
Do not start dialysis for an isolated eGFR value when the person is clinically well and no qualifying indication is present.
06
Do not attribute every pain, itch or confusion to uraemia; reversible causes remain important on a comfort-focused pathway.
07
Do not accept a withdrawal request without assessing capacity, depression, symptom control and practical treatment burdens.