Conservative kidney care matched dialysis on quality-adjusted life in frail older adults

Prepare for Kidney Care was a pragmatic phase 3 randomized trial in 31 kidney centres across England, Wales, Scotland and Northern Ireland. It enrolled people with an eGFR below 15 who were aged 80 or older, or aged 65 to 79 with frailty or multimorbidity. Participants were assigned to prepare for responsive management (focused on slowing progression, managing symptoms and preserving quality of life without dialysis) or to prepare for dialysis.

What they found

Of 6,120 people screened, 445 were randomized. Over a mean follow-up of 4.5 years, mean quality-adjusted life-years were 1.354 in the conservative care group and 1.472 in the dialysis-preparation group (adjusted difference -0.147, 95% CI -0.350 to 0.056, p=0.16). Dialysis access complications were lower with conservative care (adjusted rate ratio 0.41), and hospital admission rates were similar.

The nuance

The trial found no evidence that either path was superior, which is not the same as proving they are equal. Deaths were 69% in the conservative care group and 63% in the dialysis-preparation group. The trial was open label, and only 7% of screened patients enrolled, so results apply to people similar to those who took part.

Youthful take

For older adults facing kidney failure, the right choice depends on personal goals, function and values. This trial supports a shared decision with your nephrology team rather than a default in either direction.