Kidney palliative care: Conservative kidney management

INTRODUCTION — For some patients, dialysis offers neither a survival nor a quality-of-life advantage. Such patients should be offered conservative (nondialytic) kidney management (CKM) as an alternative to dialysis. This topic review describes CKM as a treatment option for patients with end-stage kidney disease (ESKD) who elect not to pursue dialysis or transplantation.

Other related issues such as palliative care for and ethical issues in patients with ESKD and withdrawal of dialysis are discussed elsewhere.

●(See "Kidney palliative care: Principles, benefits, and core components".)

●(See "Kidney palliative care: Ethics".)

●(See "Kidney palliative care: Withdrawal of dialysis".)

DEFINITION — CKM is a treatment option for patients with stage 5 chronic kidney disease (CKD; ie, estimated glomerular filtration rate [eGFR] <15 mL/min/1.73 m²) that focuses on providing kidney supportive care to promote quality of life without pursuing dialysis or transplantation. CKM is distinct from the predialysis care of patients with stage 5 CKD who plan to pursue kidney replacement therapy when indicated. CKM is also distinct from withdrawal of dialysis, which refers to discontinuation of maintenance dialysis. (See "Kidney palliative care: Withdrawal of dialysis".)

The guiding principle in CKM is to align care with the patient's preferences in order to achieve their personal goals, which typically focus on enhancing quality of life and improving symptoms. Interventions to delay progression of kidney disease and manage the complications of end-stage kidney disease (ESKD) may still play an important role in CKM as long as they are directed to help with the patient's specific goals. The components of CKM are discussed below. (See 'Components of CKM' below.)

Ideally, patients and their health care teams arrive at the decision to pursue CKM through shared decision-making. However, it should be recognized that some patients receive CKM due to resource constraints limiting access to dialysis; this is sometimes referred to as choice-restricted CKM.

CKM is best delivered through a collaborative, interdisciplinary team, which generally includes a nephrologist, primary care clinician, nurse, dietician, social worker, and, when appropriate, the palliative care team.

EPIDEMIOLOGY

Survival with CKM or dialysis — Survival of patients treated conservatively is variable, depending upon their comorbidities. In general, survival is longer for patients who undergo dialysis compared with CKM. However, patients who choose CKM tend to be older with greater burden of comorbidities and poorer functional status. In many studies that performed subgroup analyses, there was no difference in survival for patients with advanced comorbidities who elected dialysis compared with CKM [1-5].

Typical data comparing survival between patients who chose dialysis or CKM come from a retrospective study in which 311 patients over the age of 70 participated in discussions regarding this choice when their estimated glomerular filtration rate (eGFR) fell to <20 mL/min/1.73 m² [6]. Overall median survival was higher among patients who opted for dialysis compared with those who opted for CKM. However, the survival advantage conferred by dialysis was substantially reduced among patients who had cardiovascular or other severe comorbidities. Among patients >80 years, there was no difference in survival between dialysis and CKM groups. Similarly, a systemic review including 25 observational studies reported that the increased survival associated with dialysis compared with CKM was attenuated or absent in older patients, especially those with comorbidities [7]. A subsequent meta-analysis examined 22 observational studies that compared dialysis with CKM; the attenuated survival benefit of dialysis in older patients and those with comorbidities persisted in some multivariable and subgroup analyses [8]. However, many studies in this meta-analysis likely were limited by selection bias and/or residual confounding.

Quality of life with CKM or dialysis — Patients on dialysis experience symptom burdens similar to those with cancer; such symptoms are often under-recognized and undertreated [9]. Older patients with multiple comorbidities who start dialysis require more medical interventions and are more commonly hospitalized compared with those treated conservatively [4,10,11]. Their symptom burden is unlikely to improve substantially with dialysis. In addition, dialysis itself may cause or worsen some symptoms, such as muscle cramping and fatigue. Conversely, among patients who choose CKM, symptoms from their comorbidities or kidney failure tend to remain stable until the last two months of life, at which time they can increase sharply, requiring careful reassessment and management [12]. Many of these symptoms can be treated effectively with CKM [1]. (See 'Symptom management focused on optimizing quality of life' below.)

In one study, a cohort of older patients who elected dialysis spent approximately 50 percent of their survived days (173 days/patient/year) either receiving dialysis or in the hospital compared with patients treated conservatively who spent less than 5 percent (16 days/patient/year) of their time in the hospital [13]. Similar findings with longer hospitalizations, a higher rate of intensive care unit admission, and a lower rate of inpatient palliative care involvement have been reported among patients with end-stage kidney disease (ESKD) who were treated with dialysis compared with patients treated without dialysis [9-11,14].

Patients who choose CKM are also more likely to receive services such as palliative care and hospice to manage symptoms and end-of-life care. For example, in one observational study, patients who chose CKM rather than dialysis were more than four times as likely to die at home or in a hospice facility [13].

Utilization of CKM — In a survey of 150 countries conducted by the International Society of Nephrology, 81 percent of countries reported offering CKM [15]. In resource-limited countries, the rationing of kidney replacement therapy is common. However, the availability of CKM was not associated with country income. High-income countries were more likely to report that CKM was delivered as chosen or medically advised, as opposed to "choice-restricted." (See 'Definition' above.)

Only 38 percent of countries reported that CKM services were easily accessible, of which none were low-income [15]. Less than one-half of countries utilized multidisciplinary teams (46 percent), shared decision-making (32 percent), or provided psychological, cultural, or spiritual support (36 percent) as part of their CKM care. One-quarter of the countries trained their clinicians on delivery of CKM.

The data regarding the number of patients who actively engage in decision-making around CKM are limited. In one observational study from Australia, of the 721 patients with ESKD (mean age of 80 years), 65 percent were offered CKM as an option and 14 percent ultimately chose CKM [16].

Patients over the age of 85 years have a variable experience with dialysis initiation across different countries. As an example, in this age group, dialysis was initiated among 41 percent in the United States, 7 percent in Canada, and less than 5 percent in Australia and New Zealand [17-20]. Although shared-decision making may have led to some of these patients not opting for dialysis, the absence of dialysis alone does not constitute CKM. (See "Maintenance dialysis in the older adult", section on 'Epidemiology'.)

OFFERING CKM — Dialysis should be framed explicitly as a treatment choice rather than a default option. CKM should be offered to all patients who may not benefit meaningfully from dialysis or whose goals focus on quality over quantity of life [21,22]. CKM is a treatment option for those in whom the burdens of dialysis outweigh the anticipated benefits [21,23-25].

Ideal candidates for CKM — CKM is particularly appropriate for the following patients who are unlikely to gain survival and are at risk for hospitalizations after initiation of dialysis:

●Patients who have one or more life-shortening comorbidities (eg, end-stage heart failure or end-stage liver failure). (See 'Quality of life with CKM or dialysis' above and 'Survival with CKM or dialysis' above.)

●Patients who are frail with significant preexisting functional or cognitive impairment, who often experience accelerated functional and cognitive decline after starting dialysis [26,27].

●Patients who reside in long-term care facilities [27].

●Patients who have severe, continued, and irremediable physical or psychological symptoms or who view their current and future quality of life as unacceptable, in whom dialysis may prolong life but will also prolong suffering [28].

●Patients with irreversible mental incapacitation that interferes with their ability to understand the process, risks, and benefits of dialysis in such a way that dialysis cannot be administered safely [28]. Some examples of this include:

•Patients without decision-making capacity whose advanced care directive or the substituted judgment of a health care proxy dictate CKM instead of dialysis. (See "Ethics in the intensive care unit: Informed consent".)

•Patients who are unable to cooperate with the procedure of dialysis itself and are unable to react to the environment or people. As an example, a patient in whom restraints or sedation would be required during dialysis sessions.

•Patients who are permanently unconscious (such as the persistent vegetative state).

Older patients tend to bear a greater burden of advanced multi-morbidity and frailty, and therefore, CKM becomes increasingly relevant in this population. CKM can both avoid the potential setbacks accompanying dialysis and also provide meaningful quality of life for frail patients with advanced comorbidities. Patients who choose CKM are more likely to spend their remaining survival not being hospitalized [1,10,11]. In addition, they tend to have a greater opportunity for symptom management and end-of-life care with palliative care and hospice services compared with those who choose dialysis.

Patients with end-stage kidney disease (ESKD) can survive a significant amount of time without dialysis if there is a slow rate of estimated glomerular filtration rate (eGFR) loss [29]. Conversely, hemodialysis may hasten the loss of residual kidney function. The ability to maintain even a small fraction of residual kidney function can improve survival and quality of life [30,31].

Timing and content of the discussion — The discussion regarding CKM should occur at the time of dialysis options education. For most patients, this is when the eGFR is <20 to 30 mL/min/1.73 m². However, the timing of initial and subsequent discussions ultimately depends upon the individual clinical trajectory. Patients experiencing a decline in clinical health or rapid kidney function loss may benefit from earlier discussions. (See "Overview of the management of chronic kidney disease in adults", section on 'Choice of kidney replacement therapy'.)

Important content that should be highlighted in discussions to help patients navigate the choice between dialysis and CKM includes data on survival and quality of life, as discussed above. (See 'Survival with CKM or dialysis' above and 'Quality of life with CKM or dialysis' above.)

The conversation should involve the patient, family or caregiver, and essential members of the care team, including a nephrologist, nurse, and, when appropriate, social worker and a palliative care expert.

The decision to elect CKM should incorporate the patient's values and priorities as well as clinical prognosis. In a small qualitative study of patients and family members, participants were more receptive to CKM when this modality was referred to as an 'active' rather than passive treatment approach [32].

Care providers often struggle with these discussions. Communication frameworks and guides have been developed and applied to treatment decision making for patients with advanced chronic kidney disease (CKD), especially those who may not do well on dialysis. These tools include strategies to share patient-specific prognoses that include survival as well as quality-of-life metrics, to elicit patient goals and priorities, and to make a plan that includes what is most important to the patient [33,34]. The best case/worst case framework is an approach that prompts clinicians to tell a story about what the future may bring with different treatment options based on the best- and worst-case outcomes [35]. Education for nephrology clinicians to engage in these discussions and care for people receiving CKM has been developed [36,37].

The use of patient decision aids (PDAs), which are tools to facilitate informed decision-making, also may help [38]. An interactive CKM PDA has been developed to structure the shared decision-making process required for these conversations and to help patients and care providers make reasoned decisions about care that is compatible with the patient's goals, values, and prognosis [39]. This interactive CKM PDA is a free online tool that integrates patient-specific prognostic markers of age, comorbidity, functional status, cognitive function, and living circumstances with patients' values, preferences, and overall goals of care in order to individualize the choice of dialysis versus CKM [40]. Once CKM is chosen, this treatment plan should be reassessed as part of ongoing care as patients experience clinical or functional setbacks. This ensures that care remains aligned with their goals and preferences.

The CKM PDA was codeveloped by patients and multidisciplinary kidney health care providers and includes a six-month survival prediction using data from the United States Renal Data System (USRDS) and Medicare claims database [41]. A mortality risk score was developed and internally validated using these data. The score incorporates presence of advanced age, low albumin, a requirement of assistance with daily living, nursing home residence, and heart failure. Other studies have highlighted other factors of importance, such as presence of behavioral disorders, dementia, or significant cognitive or functional impairment [42-45].

Other web-based PDAs also are available, including the Decision Aid for Renal Therapy (DART). DART is an interactive PDA that usually takes less than an hour for patients to complete. In a trial that randomly assigned over 360 patients aged 70 years or older with nondialysis stage 4 or 5 CKD to dialysis education with DART or to usual care, scores assessing decisional quality and knowledge about ESKD were better in the DART group at three and six months of follow-up [46]. The preference for CKM increased from approximately 12 percent at baseline to 20 percent at six months in the DART group but remained stable for patients in the usual care group; however, differences in CKM preference between groups were not statistically significant.

COMPONENTS OF CKM — The CKM treatment plan is individualized for each patient. Specific interventions are chosen based upon the overall prognosis and upon patients' goals and wishes. The illness trajectory and survival of patients receiving CKM is highly variable. A patient's prognosis and quality of life may change over time, warranting modifications to the treatment plan.

Overview — A conceptual model that helps tailor CKM towards an individual patient's quality of life, projected disease trajectory, and life expectancy has been developed [47]:

●Patients with a favorable prognosis and acceptable quality of life – Such patients tend to be healthier with fewer comorbidities. The treatment plan generally includes medications that decelerate progression of kidney disease and/or medications that treat secondary complications of kidney disease, in addition to those that address symptoms. The patient determines whether potentially longer survival outweighs the burdens associated with additional medications, blood work, and clinic visits. (See 'Medical management' below.)

●Patients with an unknown prognosis and unclear quality of life – Such patients may benefit from medical management of kidney disease and/or symptom management depending upon the patient's life goals. Treatments that focus upon longevity and symptoms should be elected for patients whose goals focus on living as long as possible. Symptom management without treatments that focus on longevity may be elected for those patients whose goals focus upon the quality of life. These patients warrant close reassessment of prognosis and goals of care, with modification of the treatment plan as necessary. (See 'Medical management' below and 'Symptom management focused on optimizing quality of life' below.)

●Patients with a poor prognosis and quality of life – Such patients have a predictably poor prognosis and/or poor quality of life. A treatment plan that is focused upon medical management of kidney disease is not likely to provide meaningful benefit. Instead, the treatment plan should focus upon symptom control, comfort, and preparation for end of life, and omit medical therapies that do not address symptoms. (See 'Symptom management focused on optimizing quality of life' below.)

The components of CKM include:

●Medical management of kidney disease

●Symptom management including quality-of-life care

●Advance care planning and crisis management planning

●End-of-life care

Medical management — For patients who have a favorable prognosis and preserved quality of life, treatment that focuses on longevity is reasonable. This includes medications that decelerate progression of kidney disease and medications that treat secondary complications of end-stage kidney disease (ESKD). This management may also be reasonable for patients who have an unknown prognosis who desire to live as long as possible with the hope of achieving an acceptable quality of life. Thus, medical management in this scenario may be similar to that of chronic kidney disease (CKD) patients who are awaiting the initiation of kidney replacement therapy, with modifications as outlined below. (See "Overview of the management of chronic kidney disease in adults".)

Deceleration of kidney disease progression — Treatment options that decelerate progression among patients with specific kidney diseases, such as use of renin-angiotensin aldosterone system (RAAS) inhibitors among patients with diabetic kidney disease, can be offered to patients for whom benefits outweigh risks. Although RAAS inhibitors are beneficial in patients with CKD, most patients who receive CKM have advanced CKD or ESKD. Such patients can experience an accelerated loss of glomerular filtration rate from RAAS inhibitors, and therefore, we usually refrain from use of RAAS inhibitors even in the presence of significant proteinuria. Such patients are less likely to live long enough to experience the protective benefits and are more likely to experience worsening kidney function and hyperkalemia from these agents.

Blood pressure management — Blood pressure (BP) control is fundamental to the care of patients with CKD to slow the progression of kidney failure and to minimize cardiovascular morbidity. (See "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults".)

Among patients who have chosen CKM, the goal of BP management is to avoid the short-term deleterious effects of excessively high BPs (eg, stroke or myocardial infarction), while preserving physical and cognitive function and quality of life. Target BP should be individualized by minimizing signs and symptoms of low BP (eg, falls, lightheadedness, fatigue, and cognitive impairment). Target BP is typically ≤150/90 mmHg in such patients.

In one study, intensive BP lowering (ie, systolic blood pressure <120 mmHg versus <140 mmHg) was found to be beneficial, even among older adults over the age of 75 [48]. This has led to reassessment or changes in BP management in the population. However, these data do not apply to patients who choose CKM due to the increased rate of unacceptable adverse effects, such as acute kidney injury, electrolyte abnormalities, syncope, and injurious falls that are likely to occur in the short-term. In addition, the life-expectancy of many patients who choose CKM is less than three years, and such patients were excluded from this study.

Treatment of anemia — Among patients on the CKM pathway, we continue to administer erythropoiesis-stimulating agents (ESAs) and iron to treat anemia, as indicated. (See "Treatment of anemia in nondialysis chronic kidney disease" and "Treatment of anemia in patients on dialysis".)

Treatment of anemia can help improve symptoms of fatigue and weakness. However, as for patients with CKD and ESKD who are not managed conservatively, we do not increase ESA beyond the hemoglobin (Hb) goal of 11 g/dL. Residual symptoms of fatigue or weakness among patients with an Hb of ≥11 g/dL are unlikely to be from anemia. (See "Treatment of anemia in patients on dialysis" and "Treatment of anemia in patients on dialysis", section on 'Adverse effects of ESAs' and "Treatment of anemia in patients on dialysis", section on 'Target Hb levels'.)

We generally do not avoid ESAs for patients with an Hb <11 g/dL who are treated conservatively and who have an active malignancy or a history of stroke. This is because our focus is on improving and maintaining quality of life with treatment of anemia, rather than prolonging life expectancy. A risk-benefit discussion with such patients is often helpful.

Treatment of mineral-bone disease — Our management of hyperphosphatemia includes a moderate phosphate-restricted diet and use of phosphate binders similar to other patients with CKD. (See "Management of hyperphosphatemia in adults with chronic kidney disease".)

Parathyroid hormone (PTH) levels do not impact decision-making within this conservative approach to care and, therefore, we do not routinely monitor PTH levels or target a specific level. Although evidence remains limited [49], we continue low-dose activated vitamin D to help treat symptoms of fatigue, weakness, and muscle loss, and reduce fracture risk.  

Among patients undergoing CKM, aiming to normalize laboratory abnormalities in serum calcium, phosphate, and PTH may not be beneficial. This is because such control often comes at the cost of intense dietary restriction (eg, of protein) among patients who are already at a high risk for protein malnutrition [50].

Instead, we focus treatment goals on reducing symptoms and promoting quality of life. Hyperphosphatemia may contribute to restless leg syndrome and uremic pruritus. Calcium and phosphorous deposition can lead to myalgias, arthralgias, and pseudogout. Decreased active vitamin D can lead to weakness, fatigue, and muscle loss. Hypovitaminosis D has also been associated with fracture risk in older patients [51]. Thus, the management of metabolic abnormalities should be aimed at ameliorating these symptoms while liberalizing the diet as much as possible, thereby maintaining adequate nutrition and avoiding malnutrition.

Treatment of metabolic acidosis and hyperkalemia — Metabolic acidosis can contribute to fatigue, bone loss, muscle wasting, nausea, and malnutrition [52]. Treatment is aimed at improving these issues if the patient feels that they are contributing to a decrease in physical function and quality of life [53,54]. Metabolic acidosis can be treated with base-containing fruits and, among patients who are able to tolerate the additional sodium load and pill burden, oral sodium bicarbonate. However, the evidence that treating metabolic acidosis will improve these issues, particularly in older adults, is weak [55]. (See "Pathogenesis, consequences, and treatment of metabolic acidosis in chronic kidney disease", section on 'Treatment of metabolic acidosis in CKD'.)

Patients with advanced kidney disease often have difficulties with hyperkalemia, which can be life threatening. Among patients with hyperkalemia, we first discontinue medications that might be culprits, such as RAAS inhibitors. If hyperkalemia persists despite discontinuation of culprit medications, then we treat with dietary modification and gastrointestinal cation exchangers such as patiromer or zirconium cyclosilicate. (See "Treatment and prevention of hyperkalemia in adults", section on 'Do not use sodium polystyrene sulfonate (SPS) or other resins'.)

Additional medication changes — Medications that do not address comfort should be stopped, unless their benefits will be actualized during the patient's life expectancy. Examples include but are not limited to statins and aspirin. Medication reconciliation also allows opportunities to initiate medications that treat symptoms. Importantly, patients in the last one to two months of life often experience increasing symptoms that require active medication adjustments. (See 'Management of symptoms' below.)

Symptom management focused on optimizing quality of life — Symptom management should occur concurrently with medical management of kidney disease or as the sole treatment approach. Symptom management alone may be most appropriate for patients who have a poor prognosis, and for those whose prognosis is unknown and whose goals are for comfort.

Symptom evaluation — Patients who elect CKM experience a similar number and severity of symptoms as those on dialysis [56]. These symptoms may result from complications of advanced CKD or from coexisting conditions such as diabetes, heart failure, peripheral vascular disease, and cancer. Patients tend to under-report symptoms unless they are assessed explicitly [57]. It is therefore important to elicit physical and emotional symptoms routinely at each clinic visit [21]. Assessments can be completed by the patient with the help of a caregiver or support staff, as needed. For patients whose care is managed at home, symptom assessments can be mailed and either returned by mail or reviewed over the phone.

Patient-completed symptom assessments have been validated for CKM [58]. We use the following validated tools for symptom assessment:

●General symptom review – We use either the Edmonton Symptom Assessment System-Revised: Renal (ESAS-r:Renal) or the Integrated Palliative Care Outcome Scale-Renal (IPOS-Renal). We use these (preferably the same one) at every routine patient visit (typically every three months).  

The ESAS-r:Renal assesses the prevalence and severity of 13 symptoms using a visual analog scale (VAS) with a superimposed 0 to 10 numerical rating scale. Issues assessed include pain, activity level, nausea, depression, anxiety, drowsiness, appetite, wellbeing, shortness of breath, pruritus, sleep, and restless legs. A caregiver can complete several items on the questionnaire if the patient is too ill to participate in the evaluation. This short, practical assessment can be rapidly and repeatedly completed by patients and, therefore, incorporated easily into routine clinical care, even for patients who are preterminal. It has been translated into several languages.

The IPOS-Renal assesses 17 issues, such as pain, shortness of breath, weakness, nausea, vomiting, poor appetite, constipation, mouth problems, drowsiness, poor mobility, itching, difficulty sleeping, restless legs or difficulty keeping legs still, anxiety, depression, changes in skin, and diarrhea. These symptoms are rated in terms of their impact on the patient over the last week from 0 (not at all) to 4 (overwhelmingly). There are also additional questions that elicit caregiver anxiety, practical issues, and optional items for any other concerns.

Once a symptom is recognized, the impact on function and quality of life should be assessed to better understand the level of distress or intrusiveness of the symptom. This requires careful communication with the patient.

●Specific pain review – We use the Brief Pain Inventory. This tool helps categorize pain and assess the response to management.

●Psychological assessment – We typically use the Patient Health Questionnaire-9 (PHQ-9) to screen for depression though the Beck Depression Inventory (BDI) is a reasonable alternative.

PHQ-9 and BDI have been validated among CKD patients. We use the PHQ-9 since it is shorter and does not require adjustment for somatic symptoms. The PHQ-9 is a nine-item screening tool to assess the presence of depressive thoughts or feelings over the past two weeks. A score of 10 or higher indicates a depressive disorder [59]. The PHQ-2 is a two-question tool comprised of the first two questions from the PHQ-9 that has demonstrated validity as a screening tool for depression among CKD patients [60]. The PHQ-2 is intended to be an initial screen, and patients who screen positive should undergo confirmatory screening with PHQ-9.

The BDI is a 21-item screening tool that has been validated in CKD and ESKD patients. The cut-off score (≥10) for a depressive disorder is higher in CKD (≥11) and ESKD (≥14 to 16) patients to account for a greater somatic symptom burden in these patients [61].

Patients who screen positive for depressive symptoms require a comprehensive assessment to determine whether these symptoms stem from depression itself or spiritual/existential concerns that may accompany those living with advanced illness.

Management of symptoms — Patients with ESKD, whether managed conservatively or with dialysis, often experience a high symptom burden. The most common symptoms reported by patients managed conservatively are fatigue (77 percent), itching (67 percent), pain (62 percent), shortness of breath (61 percent), and edema (54 percent) [56,62-64]. The prevalence of other symptoms, such as loss of appetite (51 percent), problems sleeping (51 percent), and restless legs (33 percent) is also high. Symptom severity can vary.

General approach — To optimize patient safety and reduce polypharmacy, the management of all symptoms should follow a similar stepwise approach in the following order [40,65]:

●Exclude contributing, reversible factors

●Use nonpharmacologic interventions

●Use pharmacologic interventions

The aim of treatment is to ameliorate symptoms that are compromising the patient's quality of life. It is not always possible or necessary to resolve them completely.

Fatigue — Fatigue is the most common symptom among patients with advanced CKD. The evaluation of fatigue should include an assessment and management of anemia [66-69]. (See 'Treatment of anemia' above.)

Other possible contributing factors include malnutrition, volume depletion, vitamin D deficiency, abnormal thyroid function, or the use of medications such as benzodiazepines, antiepileptics, antidepressants, or opioids. Patients should also be evaluated for sleep disturbances or psychological problems such as depression, anxiety, and existential suffering. (See 'Psychological symptoms' below.)

Nonpharmacologic interventions to mitigate fatigue include improving nutrition and hydration, encouraging gentle exercise as tolerated, optimizing sleep hygiene, and identifying energy conservation strategies.

Pruritus — Pruritus is common and can be extremely bothersome to patients with ESKD. Reversible factors such as anemia, iron deficiency, xerosis, drug hypersensitivities, allergies, or contact dermatitis should be addressed.

Similar to the dialysis population, we first treat pruritus with topical treatments. For resistant symptoms, we initiate a low-dose gabapentin or pregabalin [70,71]. (See "Chronic kidney disease-associated pruritus", section on 'Management' and "Chronic kidney disease-associated pruritus", section on 'Gabapentin and pregabalin'.)

In one retrospective study of 30 patients receiving CKM who had uremic pruritus, over 80 percent experienced improvement with gabapentin [71]. The median dose achieved was 100 mg (range 39 to 455 mg).

Pain — Pain is common, distressing, and warrants a comprehensive assessment in all patients with advanced CKD, including those being cared for conservatively. Pain may be due to concurrent comorbidities (eg, diabetic neuropathy, peripheral vascular disease) or due to a secondary complication of kidney disease (eg, calciphylaxis, bone pain from renal osteodystrophy). Untreated pain can negatively impact quality of life and contribute to other symptoms such as poor sleep, anxiety, and depression. The treatment of pain in advanced CKD, including patients being cared for with CKM, is discussed elsewhere. (See "Management of chronic pain in advanced chronic kidney disease".)

Dyspnea — Possible causes of dyspnea include anxiety, anemia, infection, metabolic acidosis, and pulmonary edema. If volume overload is contributing, then sodium and fluid restriction and diuretics should be used, even at the risk of accelerating CKD progression. Nonpharmacologic interventions to relieve the sensation of breathlessness include sitting in an upright position (eg, 45 degrees), gentle air flow across the face, maintaining a humid environment, pursed lip breathing, and supplemental oxygen. (See "Kidney palliative care: Principles, benefits, and core components".)

Dyspnea may surface as a predominant symptom towards the end of life. Low-dose opioids and benzodiazepines can be useful to address dyspnea and accompanying anxiety. All opioids should be used with caution since the active metabolites accumulate in kidney failure and may contribute to neuroexcitability and myoclonus. Safer opioids include methadone and fentanyl. Active metabolites of morphine, oxycodone, and hydromorphone can accumulate in ESKD.

Nausea and vomiting — Symptoms of anorexia, nausea, and vomiting may signify advancement of kidney disease or overall decline. Common contributing factors to consider include metabolic acidosis, medications such as opioids and antidepressants, and gastrointestinal disturbances such as constipation or delayed gastric emptying.

Nonpharmacologic management of nausea and vomiting is particularly important due to the adverse effects of many of the commonly used antiemetics. Strategies, such as eating smaller, more frequent meals, eating slowly, and avoiding alcohol or foods that are greasy, spicy, or excessively sweet should be attempted. Minimizing aromas such as cooking odors, perfumes, and smoke may also help. We encourage loose fitting clothing and a relaxed, upright position after meals to facilitate digestion. Complementary therapies such as relaxation techniques or acupressure may be beneficial.

For persistent nausea or vomiting, low dose ondansetron, 4 to 8 mg every eight hours as needed or low-dose haloperidol, 0.5 mg every eight hours as needed, may be effective. Metoclopramide is a dopamine antagonist that has both antiemetic and prokinetic properties and is effective for gastroparesis and uremia. Metoclopramide should be dosed according to degree of kidney function impairment. Haloperidol and metoclopramide are dopamine antagonists and should not be prescribed together. Side effects of these agents include extrapyramidal reactions, and patients should be monitored to guide adjustments in dose or discontinuation of these medications.

Patients with persistent symptoms benefit from assessment of end-of-life needs. (See "Kidney palliative care: Principles, benefits, and core components", section on 'Nausea and vomiting'.)

Psychological symptoms — Kidney disease is a risk factor for psychological conditions such as depression and anxiety. Persistent psychological symptoms can worsen physical symptoms, negatively impact quality of life, and are associated with increased hospitalization. Conservatively managed patients face limited survival and are at risk for existential and spiritual concerns that accompany end of life.

Selective serotonin reuptake inhibitors are safe and may be preferred treatment for depression in advanced CKD. We use sertraline as a first-line agent as it does not require dose adjustment for kidney function and because it helps relieve symptoms of anxiety. (See "Depression in adults receiving maintenance dialysis", section on 'Choosing treatment'.)

Crisis planning — Crisis planning is the process of planning for future clinical setbacks, such as symptom crises, that may occur among patients who choose CKM. Crisis planning begins with advanced care planning (ACP), which is the process by which patients, family members, and providers reflect upon the patient's goals and values to help inform current and future medical care plans, including end-of-life care [72]. (See "Kidney palliative care: Principles, benefits, and core components", section on 'Advance care planning' and "Kidney palliative care: Ethics".)  

Many patients may be asymptomatic at the time CKM is elected. When symptoms do arise, patients may respond with fear and reconsider dialysis as a "fix." These sentiments were described in a qualitative study of older patients who had elected CKM. A subset of these patients described dialysis as something they would reconsider if they "had to have it" or "got really ill" [73]. Without adequate preparation, patients may view CKM as a temporary plan that may change over time, depending on their current health state and life circumstances.

Despite appropriate and adequate ACP and crisis management, patients may change their mind and request dialysis. This is not unexpected, as patient preferences are shaped by their experience, values, and uncertainty of the future. Some of these requests may reflect emotion, such as worries and fears of end of life. Such concerns should be explored and patients' goals of care should be readdressed. For seriously ill patients who are near the end of life, this approach may also require skills to manage conflict and consideration of palliative care consultation. (See "Palliative care: Medically futile and potentially inappropriate therapies of questionable benefit" and "Kidney palliative care: Ethics".)

The importance of crisis planning is illustrated by a systematic review of 41 observational studies including over 5100 patients who chose to not pursue dialysis. Physical well-being and overall quality of life were largely stable until late in the CKD course. However, many patients frequently used acute care services (eg, one to two hospitalizations and two emergency department visits per person-year) [74].

End-of-life care — Symptom burden appears to be relatively stable for patients being cared for conservatively until the last two months before death [62,75]. In a prospective cohort study of conservatively managed patients, the last two months of life were characterized by an increase in fatigue, pruritus, drowsiness, dyspnea, agitation, and pain. Additionally, patients and caregivers experienced high levels of psychological concerns, including personal and family anxiety, depressed mood, increased information needs, and practical concerns [76]. An interdisciplinary palliative care team may assist with difficult-to-treat symptoms or conflicting goals of care. Patients on CKM and their caregivers may also benefit from hospice services. A detailed discussion regarding palliative care for patients with ESKD is presented elsewhere. (See "Kidney palliative care: Principles, benefits, and core components", section on 'Terminal symptom management' and "Palliative care: The last hours and days of life".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic kidney disease in adults".)

SUMMARY AND RECOMMENDATIONS

●Definition of conservative kidney management – Conservative kidney management (CKM) is a treatment option for patients with end-stage kidney disease (ESKD; estimated glomerular filtration rate [eGFR] <15 mL/min/1.73 m²) that, through shared decision-making and holistic patient-centered care, emphasizes quality of life without pursuing dialysis or transplantation. (See 'Definition' above.)

●Epidemiology – The survival advantage conferred by dialysis, compared with CKM, is substantially reduced among patients who have cardiovascular or other severe comorbidity, and there may be no difference in survival among patients >80 years. Knowledge and utilization of CKM varies globally. (See 'Epidemiology' above.)

●Ideal candidates – Dialysis should be framed explicitly as a treatment choice rather than a default option. CKM should be offered to all patients who may not benefit meaningfully from dialysis or whose goals focus on quality over quantity of life. CKM is a treatment option for those in whom the burdens of dialysis outweigh the anticipated benefits, such as (see 'Ideal candidates for CKM' above):

•Patients who have one or more life-shortening comorbidities (eg, end-stage heart failure or end-stage liver failure).  

•Patients who are frail with significant preexisting functional or cognitive impairment, who often experience accelerated functional and cognitive decline after starting dialysis.

•Patients who reside in long-term care facilities.

•Patients who have severe, continued, and irremediable pain or another source of physical or psychosocial suffering, in whom dialysis may prolong life but will also prolong suffering.

•Patients with irreversible mental incapacitation that interferes with their ability to understand the process, risks, and benefits of dialysis in such a way that dialysis cannot be administered safely.

●When to discuss – The discussion regarding CKM should occur at the time of dialysis options education. For most patients, this is when the eGFR is <20 to 30 mL/min/1.73 m². The decision to elect CKM should incorporate the patient's values and priorities as well as clinical prognosis. (See 'Timing and content of the discussion' above.)

●Components of conservative kidney management – The CKM treatment plan is individualized for each patient. Specific interventions are chosen based upon the overall prognosis and upon patients' goals and wishes. (See 'Components of CKM' above.)

•The use of treatment for delaying progression of kidney disease or prolonging life is individualized for each patient depending upon their prognosis, quality of life, and desire to prolong life. (See 'Overview' above.)

•Medical management of an individual patient's kidney disease is based upon their symptom burden from sequelae of advanced chronic kidney disease. It may include any or all of the following: treatment of hypertension, anemia, mineral-bone disease (hyperphosphatemia and hypovitaminosis D), metabolic acidosis, and hyperkalemia. Medications that do not improve a patient's quality of life should be stopped, when possible. (See 'Medical management' above.)

•Additional medications may be required to address symptoms such as fatigue, pruritus, pain, dyspnea, nausea and vomiting, as well as psychological symptoms. (See 'Symptom management focused on optimizing quality of life' above.)

•Crisis planning, which is the process of planning for future clinical setbacks like symptom crises, should be undertaken to avoid patients from fearfully requesting dialysis as a "fix" for their worsening symptoms. (See 'Crisis planning' above.)

•Symptom burden is usually stable among patients being cared for conservatively until the last two months before death, when there is a notable increase. At such time, patients and their family members need more involved care and monitoring by hospice and palliative care personnel. (See 'End-of-life care' above and "Palliative care: The last hours and days of life" and "Kidney palliative care: Principles, benefits, and core components", section on 'Terminal symptom management'.)