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The global population is ageing, and chronic kidney disease is becoming more common. As a result, increasing numbers of older adults with multimorbidity and frailty are progressing to kidney failure. This requires all healthcare professionals involved in the care of people with kidney failure to be able to provide careful guidance with regards to available treatment options. Choosing a treatment pathway for frail patients may be challenging, particularly for those considered ineligible for kidney transplantation. For such individuals, the remaining options are dialysis and conservative kidney management (CKM). However, these treatments have not been compared in randomized trials, which often makes it difficult to determine which treatment best aligns with the needs and preferences of people living with kidney failure.

In this narrative review, we discuss CKM as a valuable treatment approach for old and frail people with kidney failure, and those considered ineligible for kidney transplantation. We compare clinical outcomes between CKM and dialysis, such as health-related quality of life and survival. We guide the identification of people who may benefit from CKM and when discussions on CKM should be initiated. We discuss shared decision-making and consider the perspectives of patients, caregivers, and clinicians. Lastly, we embed CKM within the broader context of kidney supportive care, a palliative approach that includes advance care planning, symptom management, and lifestyle modifications that can be considered irrespective of treatment modality. Regardless of whether CKM or dialysis is chosen in the end, careful consideration of treatment options can help to ensure that people with kidney failure receive care that aligns with their values, preferences, and goals.