WeeklySA_AdminCHOICE: A landmark British trial supports greater treatment choice for older people with kidney failure and other serious health problems, as WHO estimates that 674 million people worldwide live with chronic kidney disease…
By Own Correspondent
Dialysis should not automatically be the next step for older people with kidney failure who also live with frailty or multiple health conditions, a major British study has found.
The research suggests that structured care without dialysis deserves consideration alongside preparation for dialysis, with decisions guided by patients’ needs, circumstances and priorities.
Published in The Lancet, the Prepare for Kidney Care trial found that neither approach produced better outcomes when length and quality of life were considered together. The findings support more informed conversations about treatment for a group often excluded from clinical research.
Crucially, the study compared preparation for two care pathways, rather than dialysis treatment itself against no treatment. Only 28% of participants allocated to prepare for dialysis eventually started it.
The findings do not apply to people already receiving dialysis, or to younger and fitter patients, for whom dialysis and transplantation remain standard treatment options.
Both have pros and cons. They result in similar overall length and quality of life. Neither should be the default — Professor Fergus Caskey
The research comes against a substantial global burden of kidney disease. According to the World Health Organization, an estimated 674 million people have chronic kidney disease, most of them in low- and middle-income countries. This figure covers chronic kidney disease across its stages, rather than kidney failure alone.
A World Health Assembly resolution adopted in May 2025 described that burden as approximately 9% of the global population and warned that kidney disease could become the world’s fifth leading cause of death by 2050.
Chronic kidney disease develops gradually and can progress to kidney failure. WHO identifies diabetes and high blood pressure among its causes and stresses the importance of early detection through blood and urine tests.
For patients approaching kidney failure in later life, however, treatment decisions can involve difficult questions about independence, comfort, hospital visits and the burdens of medical procedures.
Led by the University of Bristol in collaboration with Bristol NHS Foundation Trust, and funded by the National Institute for Health and Care Research, the trial recruited 445 participants from 31 UK kidney centres.
Around three-quarters were aged 80 or older. The remaining participants were aged between 65 and 79 and had additional health problems.
Participants were randomly assigned either to prepare for dialysis or to prepare for responsive management, a structured form of conservative kidney management that does not include dialysis.
The study took nine years to complete, including seven years of recruitment. Participants retained the right to withdraw or change their treatment pathway.
Over an average follow-up period of 4.5 years, neither pathway showed an advantage on the combined measure of survival and quality of life.
Participants in both groups were more likely to die from other causes than to require dialysis, reflecting their complex health needs.
The results therefore should not be interpreted as proof that dialysis offers no benefit to every older patient.
Professor Fergus Caskey, the project lead and a consultant nephrologist, said the findings could change how kidney failure is discussed with older people living with other illnesses or frailty.
“This trial establishes that if you are an older person with failing kidneys and other health problems, both preparing for dialysis and conservative kidney management are worth considering,” he said.
“Both have pros and cons. They result in similar overall length and quality of life. Neither should be the default.”
Conservative kidney management remains active care. It focuses on supporting patients and managing their condition without dialysis, rather than withdrawing medical attention.
Fiona Loud, policy director at Kidney Care UK, said patients needed information, advice and support to make an informed choice. Healthcare staff also needed support to explain and deliver the available options.
She emphasised that choosing conservative care did not prevent a patient from reconsidering dialysis with their clinical team.
Professor Fliss Murtagh, director of the Wolfson Palliative Care Research Centre at the University of Hull, said many older people with advanced illness prioritised comfort, independence and quality of life.
Patients and families therefore needed to be heard and fully involved in decisions about treatment, she said.
Dialysis can place considerable demands on patients and families through repeated treatment sessions, travel and medical procedures, while also carrying risks of complications. These burdens form part of the discussion about what a particular treatment may offer an individual.
The researchers recommend that health authorities and professional bodies use the findings to strengthen guidance supporting both pathways, with decisions made jointly by patients and their healthcare teams.
For the older, frail population studied, the central message is greater choice: treatment planning should begin with a careful discussion of likely benefits, burdens and what matters most to the person receiving care. – Newswise
