Clinicians caring for patients who forgo kidney replacement therapy are adept at managing symptoms such as uremia, but fall short of providing holistic care recommended by guidelines, according to new survey findings presented at the National Kidney Foundation’s 2023 Spring Clinical Meetings in Austin, Texas.1

Susan Wong, MD, and colleagues from the University of Washington in Seattle conducted an online survey of 203 nephrology providers across the United States, of whom 49.8% were nephrologists and 50.2% were advanced practice providers.

Most providers had limited experience caring for patients with stage 4 to 5 chronic kidney disease (CKD) who decided to forgo kidney replacement therapy. A majority (61.0%) reported that such patients comprised less than 10% of their practice. More than half of respondents (54.8%) had managed 20 or fewer patients opting for conservative care during their entire careers, whereas 4.6% had never cared for such patients.

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Most providers responded that they “always” or “often” provided symptom management (81.1%), multidisciplinary care (67.2%), shared decision-making about treatment of advanced CKD (66.2%), and psychological support (51.8%) to patients. Less than half reported that they “always” or “often” trained staff on caring for these patients (47.2%) or sought spiritual support (41.6%).

Most nephrology providers reported “always” or “often” working with primary care (72.8%), palliative medicine (69.2%), hospice (63.1%), social work (58.0%), and nutrition (50.3%) services to support these patients. Fewer indicated that they “always” or “often” offered psychology (29.7%), geriatric medicine (26.6%), chaplaincy (23.1%), physical and/or occupational therapy (21.5%), and bioethics (13.3%) services.

According to a 2015 controversies conference on supportive care conducted by Kidney Disease Improving Global Outcomes (KDIGO),2 comprehensive conservative care is planned holistic patient-centered care that includes all of the following:

  • Interventions to delay progression of kidney disease and minimize risk of adverse events or complications
  • Shared decision-making
  • Active symptom management
  • Detailed communication including advance care planning
  • Psychological support
  • Social and family support
  • Cultural and spiritual domains of care

According to Dr Wong’s team, these survey findings “demonstrate the need to increase provider training in the care of patients who forgo [kidney replacement therapy] and the importance of efforts to develop models of care to improve care delivery and outcomes for these patients.”

Survey respondents practiced for a mean 14 years (age 47 years; 53.2% White; 66.0% female). The largest subgroups treated more than 100 patients per month (53.2%) and practiced in urban areas (63.5%), the South (34.5%), and private settings (36.5%).


  1. Chotivatanapong J, Prince D, Oestreich T, Wong S. Care practices for patients who forgo kidney replacement therapy: a national survey of US nephrology providers. Presented at: NKF 2023, Austin, Texas, April 11-15. Abstract 207.
  2. Davison SN, Levin A, Moss AH, et al; Kidney Disease: Improving Global Outcomes.  Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care. Kidney Int. 2015;88(3):447-459. doi:10.1038/ki.2015.110