Dialysis may not automatically be the best next step for every older person whose kidneys are failing, according to the first randomized trial to directly compare dialysis preparation with structured conservative kidney care in frail or medically complex older adults.
The UK-wide Prepare for Kidney Care trial enrolled 445 people with kidney failure from 31 kidney centres and followed them for an average of 4.5 years.
According to the randomized trial published in The Lancet, researchers found no statistically significant difference in quality-adjusted life-years between people assigned to prepare for dialysis and those assigned to a structured non-dialysis pathway known as responsive management.
The findings do not show that dialysis is ineffective in older adults. Instead, they suggest that for some older patients living with significant frailty or multiple serious health conditions, both dialysis and conservative kidney management can be legitimate treatment options, and neither should automatically be treated as the default.
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445 Older Adults Were Randomized to Two Kidney-Care Strategies
The Prepare for Kidney Care trial involved people with advanced kidney failure whose estimated glomerular filtration rate, or eGFR, was below 15 mL/min/1.73 m².
Participants were eligible if they were:
- aged 80 or older; or
- aged 65–79 with substantial frailty or multiple health conditions.
The median age was 82 years.
Researchers randomly assigned:
- 228 people to prepare for responsive management;
- 217 people to prepare for renal dialysis.
| Trial Detail | Finding |
|---|---|
| Participants | 445 |
| Kidney centres | 31 across the UK |
| Median age | 82 years |
| Responsive-management group | 228 |
| Dialysis-preparation group | 217 |
| Average follow-up | 4.5 years |
| Primary outcome | Quality-adjusted life-years |
| Journal | The Lancet |
This randomized design is important because earlier comparisons between dialysis and conservative management were mostly observational.
What Is ‘Responsive Management’?
Responsive management is a structured form of conservative kidney management.
It does not mean withholding treatment.
Patients continue to receive active medical care focused on:
- slowing kidney-disease progression where possible;
- controlling symptoms;
- managing fluid balance and anemia;
- treating other medical conditions;
- maintaining comfort and independence;
- supporting psychological and social needs.
The key difference is that the pathway does not plan for dialysis or kidney transplantation.
The Bristol NHS report on the trial emphasizes that conservative kidney management remains active treatment rather than “doing nothing.”
Researchers Looked at Both Survival and Quality of Life
The study’s primary outcome was quality-adjusted life-years, or QALYs.
QALYs combine two things:
- how long a person lives;
- the health-related quality of those years.
That is especially relevant in older patients because a treatment may extend life but also create substantial treatment burden.
Mean QALYs were:
- 1.354 in the responsive-management group;
- 1.472 in the dialysis-preparation group.
The adjusted difference was −0.147 QALYs, with a p-value of 0.16.
That difference was not statistically significant.
Researchers therefore found no evidence that one preparation strategy was superior to the other when length and quality of life were considered together.
Only 28% of Patients Preparing for Dialysis Eventually Started It
One of the most striking findings was that only around 28% of people assigned to prepare for dialysis actually went on to receive dialysis.
Many participants died from other medical conditions before dialysis became necessary.
This reflects an important reality of the trial population.
Older adults with kidney failure may also live with:
- heart disease;
- frailty;
- cancer;
- cognitive impairment;
- severe mobility limitations;
- other chronic illnesses.
For some, kidney failure may not ultimately be the condition that determines survival.
The Bristol research team noted that participants in both groups were more likely to die from other causes than to reach a point where dialysis was needed.
Hospital Admission Rates Were Similar
Researchers also examined harms and healthcare use.
Hospital admission rates were broadly similar between the two strategies.
That means the responsive-management pathway did not produce a dramatic reduction in overall hospitalization.
However, one clear difference involved dialysis-access complications.
Dialysis Access Complications Were Lower Without Dialysis Preparation
Preparing for dialysis may involve procedures to create vascular access, such as an arteriovenous fistula.
These procedures can cause:
- infections;
- clotting;
- bleeding;
- access failure;
- repeated interventions.
The responsive-management group experienced significantly fewer dialysis-access complications.
The adjusted incidence rate ratio was 0.41, meaning these events occurred substantially less often among people not preparing routinely for dialysis.
This matters because many people assigned to the dialysis pathway never ultimately started dialysis, yet some may still have undergone preparation-related procedures.
Mortality Was High in Both Groups
During follow-up:
- 157 of 228 people in the responsive-management group died;
- 136 of 217 in the dialysis-preparation group died.
These figures need context.
Participants were deliberately selected from an older and medically vulnerable population.
Roughly three-quarters were aged 80 or older, and the younger participants had substantial frailty or multimorbidity.
The trial was therefore designed to answer a difficult question specifically for people whose overall prognosis may be driven by much more than kidney disease alone.
The Trial Does Not Say Dialysis Is Useless
This distinction is critical.
The findings do not mean dialysis fails to help older people.
Dialysis remains an important and often life-prolonging therapy.
The study instead shows that among this specific group of older adults with kidney failure and major frailty or comorbidity, researchers could not demonstrate that preparing for dialysis produced better overall quality-adjusted survival than structured conservative management.
For some patients, dialysis may still offer the better balance.
For others, the burden of treatment may outweigh the likely benefit.
These Findings Do Not Apply to Younger, Fitter Patients
The results should not be generalized to everyone with kidney failure.
The Bristol researchers explicitly state that the trial does not apply to:
- younger patients;
- fitter older adults;
- people already receiving dialysis;
- patients suitable for kidney transplantation.
For those groups, dialysis and transplantation remain standard and potentially life-extending treatments.
Why Dialysis Can Be Burdensome
Hemodialysis commonly requires treatment several times per week.
Patients may spend hours at a dialysis centre and additional time travelling.
Treatment can also involve:
- vascular-access procedures;
- fatigue after dialysis;
- fluid and dietary restrictions;
- repeated blood tests;
- hospital appointments;
- complications related to access or low blood pressure.
For a frail person in their 80s, these demands can consume a large proportion of remaining time and energy.
That makes quality of life a particularly important treatment outcome.
Conservative Kidney Management Is Not Palliative Care Alone
Conservative management is sometimes misunderstood as end-of-life care.
It can include palliative approaches when appropriate, but the pathway begins much earlier.
The goal is active management of kidney failure without replacing kidney function through dialysis.
Care can include:
- blood-pressure management;
- treatment of anemia;
- symptom control;
- dietary support;
- management of swelling and breathlessness;
- advance-care planning;
- psychological support.
Patients may also change their decision later.
The trial allowed people to change treatment pathways if their preferences or health circumstances changed.
Why Previous Research Could Not Answer the Question Reliably
Older observational studies often found longer survival among patients receiving dialysis.
But patients who receive dialysis are frequently healthier to begin with.
People choosing conservative care may be:
- older;
- frailer;
- more dependent;
- living with more serious diseases.
That creates selection bias.
Even sophisticated statistical adjustment may not remove all those differences.
Randomization helps balance such factors between groups, making Prepare for Kidney Care particularly important.
It provides much stronger evidence than simply observing what happens to patients who independently choose different treatments.
Only 7% of Screened Patients Were Randomized
The trial still has limitations.
Researchers screened 6,120 people, but only 445, or about 7%, were ultimately randomized.
That means the participants may not perfectly represent every older adult with kidney failure.
People willing to enter a study where either dialysis preparation or conservative care could be assigned may differ from patients who already have a strong treatment preference.
The results should therefore be applied to patients resembling the trial population rather than universally.
The Trial Compared Care Strategies, Not Fixed Treatments
Another important detail is that participants were randomized to prepare for dialysis or prepare for responsive management.
They were not forced to remain on the assigned pathway.
This reflects real clinical practice.
Health can change.
Patient priorities can change.
Someone initially planning conservative care may later choose dialysis, while someone preparing for dialysis may eventually decide against it.
The study therefore compares two decision pathways rather than two rigid treatments.
Why Shared Decision-Making Matters
Professor Fergus Caskey, who led the trial, said the findings mean that both treatment approaches should be considered valid options for older people with kidney failure and major frailty or multimorbidity.
That means treatment discussions should include:
- expected prognosis;
- frailty;
- other illnesses;
- treatment burden;
- independence;
- personal goals;
- family circumstances;
- preferences about life extension versus treatment intensity.
A decision that is right for one 82-year-old patient may not be right for another.
The Study Could Change Kidney-Care Conversations
The most important consequence of the trial may be how treatment choices are presented.
Historically, patients may have been offered dialysis as the presumed next step when kidney function deteriorated.
The new evidence supports a more balanced conversation.
For suitable older, frail patients, clinicians may be able to say that:
Dialysis preparation and structured conservative kidney management are both evidence-based options, and neither was clearly superior in overall quality-adjusted survival in this randomized trial.
That is a very different clinical discussion from assuming dialysis is automatically necessary.
What the Trial Really Shows
The study does not show that people live equally long with or without dialysis in every circumstance.
It shows something more specific and clinically useful.
Among older adults with kidney failure plus substantial frailty or multimorbidity, preparing for dialysis did not produce clearly better combined quality and length of life than preparing for structured conservative management over an average 4.5 years.
The findings support a shift away from automatic treatment pathways toward individualized kidney care.
For some patients, dialysis will remain the preferred choice.
For others, active non-dialysis treatment may offer a similarly reasonable path while avoiding some of the procedures and burdens associated with dialysis preparation.
