Synopsis
Plan ahead with people approaching kidney failure, compare replacement therapies with comprehensive conservative management, and translate an informed preference into coordinated, symptom-focused care.
- 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.
Key red flags
Severe breathlessness with hypoxaemia or pulmonary oedema needs same-day emergency assessment and may require urgent ultrafiltration or dialysis despite previous stable planning.
Investigation priorities
Estimate the pace of kidney failure and identify urgent biochemical indications for treatment.
Confirm capacity, understanding, proxy decision-makers, escalation preferences and preferred place of care.
Management branches
Risk and trajectory suggest kidney replacement therapy or conservative care may be needed within the planning horizon.
- Arrange multidisciplinary education using accessible language, interpreters and decision support, inviting family or carers if the person wishes.
- Compare transplantation, each dialysis setting and comprehensive conservative care using individual comorbidity, likely burden and personally meaningful outcomes.
Key medicines
Loop diuretic for residual diuresisSelect and titrate an oral or parenteral renal regimen with specialist input according to urine output and congestion.
Renally appropriate opioidChoose the agent, route and low starting dose from the local renal palliative protocol, then titrate to response.