Background: Should Dialysis Be the Default for Older Kidney Failure Patients?
Dialysis has long been regarded as the standard treatment for older patients with kidney failure. However, a world-first randomized controlled trial led by the University of Bristol suggests otherwise: dialysis should not necessarily be regarded as the default option for older people with kidney failure. Published in The Lancet, the study indicates that a structured, less medicalised approach without dialysis may offer an alternative without compromising a person's overall length and quality of life.
Study Design: 445 Participants Over Nine Years
The trial, called "Prepare for Kidney Care," was funded by the National Institute for Health and Care Research (NIHR). It investigated whether older people living with kidney failure and multiple health conditions or frailty would benefit more from dialysis or from a structured programme of care that does not include dialysis. The team recruited 445 participants from 31 UK kidney centres, representing around half of all UK kidney services.
- Around 75% of participants were aged 80 or over
- The remaining 25% were aged 65–79 and had additional health problems
- Participants were randomly allocated to "prepare for renal dialysis" or "prepare for responsive management" (a form of conservative kidney management)
- The study took nine years to complete, including seven years to recruit
Key Findings: Both Approaches Yield Similar Outcomes
Over an average follow-up period of 4.5 years, the study found neither approach resulted in better outcomes when length and quality of life were considered together. Notably, only one in four people (28%) who were preparing for dialysis went on to start treatment. Participants in both groups were more likely to die from other causes than to require dialysis, reflecting the vulnerability and complex health needs of this population.
Project lead Fergus Caskey, Professor of Renal Medicine at Bristol Medical School and Consultant Nephrologist at Bristol NHS Foundation Trust, said: "Our findings could have global implications for how kidney failure is discussed and managed in older patients living with multiple health conditions or frailty. Conservative kidney management is an active treatment that does not include dialysis. It is increasingly recognised around the world, but until now there has been limited evidence to compare both approaches."
Expert Perspectives: Neither Should Be the Default
Professor Caskey emphasised: "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. Both have pros and cons. They result in similar overall length and quality of life. Neither should be the default."
Fiona Loud, Policy Director at Kidney Care UK, explained: "Making a treatment decision when you have kidney failure is extremely daunting. This study has made an important contribution to something that was previously missing; data on balancing choices if someone is older and frail and has a number of other health conditions."
Professor Fliss Murtagh, Director of the Wolfson Palliative Care Research Centre at Hull York Medical School, said: "We know that many older people living with advanced illness prioritise quality of life, comfort and independence. This important research provides robust evidence that those experiencing kidney failure in later years have options which offer broadly equivalent outcomes."
The Burden and Cost of Dialysis
Dialysis can place a considerable burden on patients and families, often requiring frequent travel, regular treatments and medical procedures, while also carrying the risk of complications. With costs estimated at around £35,000 per patient each year, dialysis also represents a significant commitment of NHS resources.
Implications for Clinical Practice
The study's research team recommends that NHS England, devolved health bodies, the UK Kidney Association and NICE use these findings to support their guidance that both treatment approaches should be presented as equally valid options, with decisions made jointly by patients and their healthcare teams. The results do not apply to people already receiving dialysis, or to younger and fitter patients, for whom dialysis and transplantation remain standard care.
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