The Advancing American Kidney Health Initiative, announced in July 2019, aims to expand services for patients with chronic kidney disease (CKD). Now a new editorial published in the New England Journal of Medicine argues for the expansion of CKD management options.

Clinicians typically portray dialysis and palliative care as opposite ends of the treatment spectrum. Integrative options are a potential middle course, according to the editorial.

“We call for increased support for collaborative efforts and amended policies so that patients may have a better range of options for their care; enjoy improved quality of life, including better management of pain and other symptoms; and have their goals supported and realized,” wrote Kamyar Kalantar-Zadeh, MD, MPH, PhD, and Solomon Liao, MD, of the University of California Irvine, and Aaron Wightman, MD, of the University of Washington in Seattle, Washington.

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They discussed several expanded options:

First, conservative and preservative management of CKD should be optimized to delay dialysis initiation, including new pharmacotherapies and increased attention to improving pain, fatigue, and mental health.

Second, patients with advanced CKD could make a gradual transition to dialysis, perhaps initiating once- to twice-weekly hemodialysis or less-than-daily peritoneal dialysis at home, which may preserve residual kidney function longer than conventional dialysis.

Third, efforts can be made to shift palliative care consultations from the hospital to outpatient services to allow goal setting while the patient is still well enough to make decisions.

Finally, clinicians could offer palliative dialysis with a gradual decrease in frequency and intensity to manage symptoms and provide comfort. Dialysis could be combined with hospice care, and home dialysis could be offered at nursing homes or skilled nursing facilities.


Kalantar-Zadeh K, Wightman A, Liao S. Ensuring choice for people with kidney failure — dialysis, supportive care, and hope [published online July 9, 2020]. N Engl J Med. 383:99-101. doi: 10.1056/NEJMp2001794