Conservative kidney failure management maintains quality of life, but it often leads to intensification of services near the end of life for patients with advanced chronic kidney disease (CKD) who choose to forgo dialysis, according to a systematic review.

“These findings suggest that advances in research and health care delivery are needed to optimize outcomes among patients who are not treated with dialysis,” Susan P.Y. Wong, MD, MS, of Renal Dialysis Unit in Seattle, Washington, and colleagues stated in JAMA Network Open.

In their systematic review of 41 studies including 5102 adults with advanced CKD who chose not to pursue dialysis, median survival ranged from 1 to 41 months with a baseline mean estimated glomerular filtration rate (eGFR) of 7 to 19 mL/min/1.73 m2.

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Over 8 to 24 months, mental wellbeing improved, whereas physical wellbeing and overall quality of life remained stable until late in the disease course, the investigators reported.

Use of acute care services was common toward the end of life and intensified for a subset of patients. Patients generally experienced 1 to 2 hospital admissions, 6 to 16 in-hospital days, 7 to 8 clinic visits, and 2 emergency department visits per person-year, data indicated.

Among patients who died, 20% to 76% had enrolled in hospice, 27% to 68% died in a hospital setting, and 12% to 71% died at home, Dr Wong and colleagues reported. As many as 57% to 76% were hospitalized, and 4% to 47% received an invasive procedure during the final month of life.

According to Dr Wong’s team, conservative kidney failure management may be a positive therapeutic alternative to dialysis when there is a multidisciplinary approach to care and aggressive symptom management.

In an accompanying editorial, Christine K. Liu, MD, MS, and Manjula Kurella Tamura, MD, MPH, of Veteran Affairs Palo Alto Health Care System, Palo Alto, California, commented:

“The work by Wong et al dispels the notion that conservative care for kidney failure means a grim and near-immediate death. Considered against available data on the survival and quality of life provided by dialysis, the study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients’ life goals.”

The decision to initiate or forgo dialysis is likely “one of the most consequential decisions” patients, their caregivers, and providers will face, according to the editorialists. Although guidelines recommend that patients should receive information about all treatment options for kidney failure to improve decision making, current practice often falls short of these ideals.


Wong SPY, Rubenzik T, Zelnick L, et al. Patients with advanced kidney disease who forgo maintenance dialysis: a systematic review. JAMA Netw Open. Published online March 14, 2022. doi:10.1001/jamanetworkopen.2022.2255

Liu CK, Tamura K. Conservative care for kidney failure — The other side of the coin. JAMA Netw Open. Published online March 14, 2022. doi:10.1001/jamanetworkopen.2022.2252