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.
- 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.
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.
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.
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.
- Assess transplant eligibility and living-donor possibilities while evaluating vascular access, abdominal suitability, home circumstances and support needs.
- Document a preferred pathway and contingency option, then review after clinical change rather than treating the first choice as irrevocable.