Conservative Kidney Management in Elderly Patients Not Receiving Dialysis - How to Proceed?

Sep 30, 2026

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Rising numbers of older adults develop ESKD, and conservative kidney management (CKM) remains underused despite guidance that conservative renal care is a reasonable option for patients who do not wish to pursue KRT. A Kidney360 editorial summarizes a retrospective cohort analysis of adults aged 75+ with low eGFR who did not receive KRT, comparing CKM versus non-CKM groups. CKM was associated with lower hospitalization rates without affecting overall survival, while methodological limits—selection bias, administrative-claims constraints, and lack of symptom and care-type detail—limit internal validity and prevent conclusions about patient wellbeing.

LanguageEnglish

CategoryHealthcare

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Editorial: Conservative Kidney Management in Elderly Patients Not Receiving Dialysis - How to Proceed?

Epidemiology and rationale for CKM

Study design and patient groupings

Statistical methods and key findings

Limitations affecting internal validity

CKM as an active, structured care approach

Clinical outcomes beyond mortality and hospitalization

Editorial Conservative Kidney Management in Elderly Patients Not Receiving Dialysis How to Proceed? Abdullah Al-Muhaiteeb Kidney360 6: 1645–1646, 2025. doi: [https://doi.org/10.34067/KID.0000000977](https://doi.org/10.34067/KID.0000000977) The number of elderly patients developing ESKD has been steadily increasing.1,2 In 2022, the adjusted incidence rate was 1461 per million population among individuals aged 75 years and older.3 Despite advances in technology and the growing availability of dialysis options, conservative kidney management (CKM) remains an underutilized approach. Many of these older patients are frail and burdened with multiple comorbidities, raising important questions about the most appropriate and compassionate course of care. According to the Kidney Disease Improving Global Outcomes 2024 guidelines,4 conservative renal care is a reasonable option to consider for patients who do not wish to pursue KRT. In this issue of Kidney360, Kobayashi et al.5 conducted a retrospective cohort study using data from a national health examination cohort, spanning from April 2014 to May 2023. The data, provided by DeCS HealthCare Inc.(Tokyo, Japan), included health insurance claims records. The study population consisted of individuals aged 75 years or older with an eGFR of ,8 ml/min who did not receive KRT. The authors divided patients into two groups: the CKM group and the non-CKM group. The CKM group included those who underwent no procedures related to KRT, while the non-CKM group consisted of patients who had undergone procedures such as vascular access surgery or peritoneal dialysis (PD) catheter insertion. For statistical analysis, a Cox proportional hazards model was used to evaluate mortality, while age, sex, body mass index, frailty, and renal function were assessed as factors inﬂuencing CKM selection. In addition, a Poisson regression model was used to calculate incidence rate ratios for hospitalization. Frailty was assessed using the Electronic Frailty Index. The study found that the CKM group had signiﬁcantly lower hospitalization rates compared with the non-CKM group, without any signiﬁcant effect on overall survival. Although the study addresses a clinically important and relevant issue, which is the beneﬁt of KRT in a vulnerable elderly population, it has signiﬁcant ﬂaws and limitations that threaten its internal validity. Most notably, the study population was drawn from a health checkup database, which may not be representative of the broader population of older adults with stage 5 CKD. Individuals who undergo routine health checkups are often healthier or more health conscious than those who do not, introducing a potential selection bias. As a result, the beneﬁts of CKM may be overestimated, since the study participants likely had fewer comorbidities and better overall health than the general elderly CKD population. Another limitation of the study is its use of administrative claims data, which often lacks detailed clinical information. Important factors such as patient preferences, clinical presentations, and the presence of uremic symptoms or heart failure were not available. The absence of this information may have led to incorrect classiﬁcation of patients into the CKM or non-CKM groups and could also compromise the internal validity of the study's ﬁndings. In addition, the study did not explore the nature of care received by patients in the CKM group. For example, whether they received supportive care or palliative care. Clarifying this distinction would offer greater insight into patient well-being and the management of symptoms. Nephrology Division, Al Amiri Hospital, Kuwait City, Kuwait Correspondence: Dr. Abdullah Al-Muhaiteeb, email: [muhaitku@gmail.com](muhaitku@gmail.com) See related article,“Comprehensive Conservative Kidney Management among Older Population: A Nationwide Administrative Claims Database Analysis,” on pages 1713–1721. Copyright © 2025 The Author(s)

FAQs

Why is conservative kidney management considered for elderly patients who do not want KRT?

CKM is framed as a reasonable alternative under Kidney Disease Improving Global Outcomes 2024 guidance for patients who do not wish to pursue KRT. The editorial highlights frailty and multiple comorbidities as factors that make a compassionate care course important.

What did the referenced retrospective cohort study compare, and what were the results?

It compared a CKM group with a non-CKM group among individuals aged 75+ with low eGFR who did not receive KRT. The CKM group showed significantly lower hospitalization rates than the non-CKM group, with no significant effect on overall survival.

What key limitations could bias the study’s conclusions about CKM?

Selection bias may occur because participants came from a health checkup database. Administrative claims data also lack detailed clinical information such as preferences and symptom status, which can lead to misclassification and leave unmeasured confounders unaddressed.

Sep 30, 2026

Uploaded by Terk