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The Prepare for Kidney Care trial found no advantage for either preparing for dialysis or structured kidney care without dialysis when survival and quality of life were considered together. Only 28% of participants assigned to prepare for dialysis went on to start it; the results apply to older people with frailty or other health problems, not younger, fitter patients or people already on dialysis.
A UK randomized trial led by the University of Bristol found that, for older people with kidney failure who also have frailty or multiple health conditions, preparing for dialysis and receiving structured kidney care without dialysis produced similar outcomes when survival and quality of life were considered together. The findings challenge treating dialysis as the automatic next step for this group, while leaving the choice between approaches to patients and their care teams.
The Prepare for Kidney Care trial, published in The Lancet, enrolled 445 people at 31 UK kidney centers. About three-quarters were aged 80 or older; the rest were aged 65 to 79 and had additional health problems. Participants were randomly assigned to prepare for dialysis or to prepare for responsive management, a form of conservative kidney care that does not include dialysis, and were followed over time.
Across an average follow-up of 4.5 years, neither approach produced better results on the combined measure of length and quality of life, according to the study report. Among those assigned to prepare for dialysis, 28% went on to start treatment. Participants in both groups were more likely to die from other causes than to reach the point of needing dialysis, reflecting the health needs of the population studied.
The research took nine years to complete, including seven years of recruitment. The study team said participants could leave the trial at any time, and could change their treatment pathway. Conservative kidney management is an active form of care, not an absence of treatment; the trial findings do not mean dialysis is unsuitable for every older person.
How the Findings Could Change Kidney Care
The results add randomized evidence to a decision that can affect an older patient’s daily routine, care needs and priorities. Dialysis can involve regular treatment and its associated demands, while conservative kidney management focuses on care without dialysis. The trial suggests that, among the people it studied, planning for dialysis did not improve the combined outcome of survival and quality of life compared with the alternative approach.
That makes the findings relevant to shared decision-making: patients and families can discuss both pathways with clinicians rather than assuming dialysis is inevitable. The study does not establish that the approaches are identical in every respect or equally suited to each person. Individual health, preferences and goals remain part of the decision.
Kidney Care UK policy director Fiona Loud said the research supplies data that had been missing for decisions involving older people who are frail and have other health conditions. She also said health service staff need support to help patients make informed choices, and that access to appropriate care should not depend on where a person lives.
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A Trial Focused on Frailer Patients
Dialysis and transplantation remain standard care for younger and fitter people with kidney failure, according to the report. The trial’s conclusions are narrower: they concern older adults with frailty or additional health problems who are considering how to manage kidney failure. Its findings do not apply to people who are already receiving dialysis.
The trial was led by the University of Bristol with Bristol NHS Foundation Trust and recruited patients from 31 UK kidney centers, described in the report as representing around half of UK kidney services. Researchers compared preparation for dialysis with a planned, responsive approach that did not include dialysis, examining both survival and quality of life. The study was designed to provide evidence for patients, families and clinicians facing these choices and to inform discussion of NHS care.
Professor Fergus Caskey, the trial’s project lead and a renal medicine professor at Bristol Medical School, said there had previously been limited evidence directly comparing the approaches. He characterized both as options with advantages and disadvantages and said neither should automatically be treated as the default for an older person with other health problems.
“The findings will help support more personalized care, patient choice and better-informed decisions.”
— Fliss Murtagh, director of the Wolfson Palliative Care Research Center at Hull York Medical School
Limits of the Trial Evidence
The reported result is specific to the participants and outcome assessed: older people with kidney failure and frailty or other health problems, with survival and quality of life considered together. The source does not provide detailed results for each outcome separately, or establish whether particular subgroups benefited more from one approach. It also does not report the precise quality-of-life measures or the full range of treatment burdens and preferences.
The 28% figure describes participants assigned to prepare for dialysis who later started it; it is not a measure of how many people with kidney failure generally need dialysis. The study does not apply to younger, fitter patients, people already receiving dialysis, or decisions about transplantation. How the findings should change NHS practice, and whether access to conservative care is consistent across the country, remain open questions.
Putting Results Into Practice
The trial’s findings are expected to inform discussions among kidney teams, patients and families, as well as consideration of NHS policy. Clinicians will need to explain that conservative kidney management is an active care pathway and that, as Loud noted, a patient can change their mind and move to dialysis if they wish. The study report does not set out a timetable for policy changes or new national guidance.
For people weighing these options, the immediate next step is a discussion with their kidney care team about likely benefits, burdens and what matters most to them. The research supports offering a genuine choice to the group studied; it does not prescribe one pathway for all patients. Further detail on outcomes by subgroup and the practical impact on care services would help clarify how widely the findings can be applied.
Key Questions
What did the Prepare for Kidney Care trial find?
For the older participants with kidney failure, frailty or other health problems, the trial found no better combined survival and quality-of-life outcome for preparing for dialysis than for structured kidney care without dialysis.
Does the study show that older people should avoid dialysis?
No. It found that neither approach should automatically be the default for the population studied. The choice depends on the individual, and the findings do not say dialysis is unsuitable for every older person.
What is conservative kidney management?
In this study, it was called responsive management: an active approach to kidney care that does not include dialysis. Patients could change their treatment pathway, according to the trial report.
Who was included in the trial?
The trial recruited 445 people from 31 UK kidney centers. About 75% were aged 80 or older; those aged 65 to 79 had additional health problems. The results do not apply to younger, fitter patients or people already on dialysis.
How many participants assigned to prepare for dialysis started it?
28% of participants assigned to prepare for dialysis went on to start treatment during the study. That figure describes this trial group, not all older people with kidney failure.
Source: medicalxpress.com
