Kidney failure in older people: dialysis plans showed no clear edge

Four hundred and forty-five people with kidney failure, median age 82, were randomly assigned in 31 kidney centres across England, Wales, Scotland and Northern Ireland to one of two paths: prepare for dialysis, or prepare for care without it. The Prepare for Kidney Care trial, run by a team from the University of Bristol and other UK centres and funded by the National Institute for Health Research, was published online in The Lancet on 4 November 2026.

Everyone in the trial had an estimated glomerular filtration rate below 15 mL/min per 1.73 m², confirmed by at least one earlier reading that was not due to acute kidney injury. They were either 80 or older, or 65 to 79 with frailty or multimorbidity, defined as a WHO performance status of 3 or more or a Davies comorbidity score of 2 or more. Of 6,120 people screened, 7% were eligible and agreed to take part.

Care without dialysis is a plan, not an absence of treatment

The comparison arm followed what the authors call responsive management, a protocolised version of conservative kidney management. It aims to slow the decline of kidney function, treat symptoms actively and preserve quality of life, without dialysis or a kidney transplant. The other group prepared for dialysis. The trial was open-label: patients and doctors knew which path had been assigned.

Neither path came out ahead on quality-adjusted life

The main measure was quality-adjusted life-years (QALYs), which combine how long a person lives with how they rate their own health on the EQ-5D-5L questionnaire. After a mean follow-up of 4.5 years, the group preparing for care without dialysis had 1.354 QALYs on average and the group preparing for dialysis 1.472. The adjusted difference was −0.147 QALYs, with a 95% confidence interval from −0.350 to 0.056 (p=0.16). The authors conclude that they found no evidence that either approach was superior.

During follow-up, 157 of 228 people (69%) died in the group preparing for care without dialysis and 136 of 217 (63%) in the group preparing for dialysis. The abstract does not report a formal statistical comparison of deaths, so these figures should not be read as a measured difference in survival. Hospital admission rates were similar. Dialysis access complications were lower in the group preparing for care without dialysis (adjusted incidence rate ratio 0.41, 95% CI 0.19 to 0.88), but specific harms outcomes were not prespecified and this one rests on 74 events in 36 people.

Where the evidence stops

An interval running from 0.350 QALYs fewer to 0.056 more does not prove the two paths are equal; it means the trial could not separate them. The study compared preparation strategies, and the abstract does not say how many people in each group actually started dialysis. The results describe people like those enrolled: people with kidney failure in UK kidney services aged 80 or over regardless of frailty, or aged 65 to 79 with frailty or multimorbidity. The trial did not enrol younger or fitter patients.

Before this trial, the authors note, the comparative effectiveness of the two approaches in this group was unknown. The trial gives patients and kidney teams randomised numbers to weigh against personal priorities; the choice itself is worth discussing with a kidney doctor.

This article is for information only and does not replace a consultation with a doctor.

Sources

• Caskey FJ, Worthington J, Liu Y, et al. Preparing for responsive management versus renal dialysis in older people living with kidney failure and frailty or multimorbidity in the UK (Prepare for Kidney Care): a two-arm, superiority, parallel-group, open-label, pragmatic, phase 3, individually randomised controlled trial. Lancet, online 4 November 2026; registration ISRCTN17133653. doi:10.1016/S0140-6736(26)01818-001818-0) · PubMed 42982076