Renal replacement therapy and conservative management – NICE guideline

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This National Institute for Health and Care Excellence (NICE) guideline offers recommendations on renal replacement therapy (including transplant) and conservative management.

Key recommendations

Indications for starting dialysis

  • Consider starting dialysis when indicated by the impact of symptoms of uraemia on daily living, or biochemical measures or uncontrollable fluid overload, or at an estimated glomerular filtration rate (eGFR) of around 5 to 7 ml/min/1.73 m2 if there are no symptoms.
  • Ensure the decision to start dialysis is made jointly by the person (or, where appropriate, their family members or carers) and their healthcare team.

Preparing for renal replacement therapy or conservative management

  • Start assessment for RRT or conservative management at least 1 year before therapy is likely to be needed, including for those with a failing transplant.

Choosing modalities of renal replacement therapy or conservative management

  • Ensure that decisions about RRT modalities or conservative management are made jointly with the person (or with their family members or carers for children or adults lacking capacity) and healthcare team, taking into account:
    • predicted quality of life
    • predicted life expectancy
    • the person’s preferences
    • other factors such as co-existing conditions.
  • For people who choose haemodialysis/haemodiafiltration (HD/HDF):
    • consider HDF rather than HD if in centre
    • consider HDF or HD at home, taking into account the suitability of the space and facilities.
  • Include living donor transplantation in the full informed discussion of options for RRT.
  • Offer a pre-emptive living donor transplant (when there is a suitable living donor) or pre-emptive listing for deceased donor transplantation to people considered eligible after a full assessment.
  • Do not exclude people from receiving a kidney transplant based on BMI alone.

Renal replacement therapy (RRT) is a term used to encompass life-supporting treatments for severe acute kidney injury (AKI) or stage five chronic kidney disease (CKD). It includes all types of dialysis and renal transplantation. These are collectively referred to in the guideline as modalities of RRT.

Conservative management is full supportive management (including the control of symptoms and complications and advance care planning) for those in the later stages of CKD who, in conjunction with carers and the clinical team, decide against RRT.

You can read the guideline on NICE's website.