Clinical bottom line
Advanced chronic kidney disease (CKD) patients in palliative care settings often experience complex symptom burdens including pain, fatigue, pruritus, and fluid overload. Optimizing symptom management requires a multidisciplinary approach that balances conservative medical management with patient-centered goals, especially when dialysis is not pursued or is withdrawn. Emerging evidence supports ambulatory kidney supportive care models and individualized care plans that integrate symptom control, psychosocial support, and advance care planning. However, evidence gaps remain regarding standardized protocols and best practices in diverse healthcare settings.
What the evidence shows
Conservative or active medical management without dialysis can be a viable option for selected patients with advanced CKD, focusing on symptom relief and quality of life rather than life prolongation (Li et al., 2020). This approach emphasizes managing symptoms such as uremic pruritus, nausea, fatigue, and fluid overload through pharmacologic and non-pharmacologic means, tailored to patient preferences.
Palliative care integration in CKD, including for kidney transplant recipients experiencing graft failure, is increasingly recognized as essential for addressing complex symptomatology and psychosocial needs (Ma et al., 2024). These patients benefit from coordinated care that includes symptom management, psychosocial support, and clear communication about prognosis and treatment options.
Implementation of ambulatory kidney supportive care programs in safety-net hospitals demonstrates feasibility and potential to improve symptom control and patient satisfaction, particularly in resource-constrained environments (Scherer et al., 2025). Such programs often combine nephrology and palliative care expertise to optimize individualized care plans.
Conservative treatment and end-of-life care in CKD require careful decision-making, especially in older adults or those with significant comorbidities, where dialysis may not confer survival or quality-of-life benefits (Rosansky et al., 2017; Moss et al., 2023). Shared decision-making frameworks and advance care planning are critical components to align care with patient goals.
In low-resource settings, palliative care for CKD patients faces additional challenges including limited access to dialysis and symptom management resources, underscoring the need for adaptable care models and education (Sserusiba et al., 2025).
Caveats and uncertainty
The evidence base for symptom management strategies specific to advanced CKD in palliative care remains limited, with few randomized controlled trials and heterogeneous patient populations. Most data derive from observational studies, expert consensus, and extrapolation from general palliative care principles.
There is variability in how conservative management is defined and implemented, complicating comparisons across studies. Symptom assessment tools tailored for CKD populations are underdeveloped, which may hinder standardized symptom monitoring.
Implementation studies like Scherer et al. (2025) are promising but limited to specific healthcare systems, and their generalizability to other settings, especially outside high-income countries, requires further validation.
Ethical considerations around dialysis withdrawal or withholding remain complex and culturally sensitive, necessitating individualized approaches and multidisciplinary involvement.
How this may change practice
Clinicians caring for advanced CKD patients in palliative care settings should consider early integration of kidney supportive care models that emphasize symptom management, psychosocial support, and shared decision-making. This includes routine assessment of symptom burden and advance care planning discussions tailored to patient values.
Adopting ambulatory supportive care programs may improve access and continuity of care, particularly for vulnerable populations. Training nephrology and palliative care teams in collaborative care delivery can enhance symptom control and quality of life.
Recognizing conservative management as a legitimate and patient-centered approach may reduce unnecessary dialysis initiation in patients unlikely to benefit, aligning treatment with goals of care.
In resource-limited settings, adapting palliative care principles to CKD management with available resources is critical, highlighting the need for education and policy support.