Key messages

• The proportion of older people (65 years or older) with kidney failure (a condition where the kidneys no longer function well enough to keep a person alive) is increasing.

• Dialysis may be preferred by some older people with kidney failure over conservative kidney management (a non-dialysis approach to kidney failure, focusing on managing kidney symptoms and prioritising the person's quality of life). However, research gives us very uncertain answers.

• We are unsure whether conservative kidney management has any impact on life expectancy or quality of life in people with kidney failure when compared to dialysis because of a lack of robust evidence.

Why do older people with kidney failure opt for conservative kidney management over dialysis?

The proportion of older people (older than 65 years) with kidney failure (a condition where the kidneys no longer function well enough to keep a person alive) is increasing. Older people with kidney failure may refuse dialysis (a mechanical procedure where a machine is used to remove waste products and excess salts and fluid from the blood when the kidneys stop working properly) because they are concerned that this therapy may further exacerbate muscle weakness, increase hospital admissions, impair their quality of life, and increase the risk of death. Conservative kidney management is a non-dialysis approach to kidney failure, focusing on managing kidney symptoms and prioritising the person's quality of life over life extension via artificial means such as dialysis.

What did we want to find out?

We wanted to find out if survival and quality of life are similar for older people with kidney failure who undergo conservative kidney management compared to those who undergo dialysis.

What did we do?

We searched for randomised (studies in which people are randomly assigned to different treatment options) and non-randomised studies comparing conservative kidney management with dialysis among older people with kidney failure. We compared and summarised the results of these studies and rated our confidence in the evidence, based on factors such as trial methods and sample size.

What did we find?

We found no randomised studies and 24 non-randomised studies involving 24,757 people. It is unclear if conservative kidney management has an effect on death (any cause), cardiovascular death, and health-related quality of life in older people with kidney failure compared to those undergoing dialysis.

What are the limitations of the evidence?

Most studies had small sample sizes, and there were not enough studies to conclusively assess the impact of conservative kidney management on outcomes such as cardiovascular events, health-related quality of life, and hospitalisation rates. Not all studies provided data about the outcome we were interested in, and we are unsure about the results.

How up to date is this evidence?

The evidence is current to September 2025.