Conservative Kidney Management in Kidney Transplant Populations

Abstract

Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m²) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.

Keywords: Allograft failure; conservative kidney management; end-stage kidney disease; kidney transplant; palliative care; shared decision making.

Figure 1.

Trajectory of glomerular filtration rate after kidney transplantation. The main profiles of kidney function identified using latent class mixed models. Estimated glomerular filtration rate (eGFR) trajectory 1: patients with high baseline renal function (~70 mL/min per 1.73 m²) that remained stable; eGFR trajectory 2: patients with very high baseline kidney function (~90 mL/min per 1.73 m²) with slightly decreasing function over time; eGFR trajectory 3: patients with high baseline kidney function (~70 mL/min per 1.73 m²) and fast decline over time; eGFR trajectory 4: a pattern of intermediate baseline eGFR (~55 mL/min per 1.73 m²) and stability over time; eGFR trajectory 5: intermediate/low baseline eGFR (48 mL/min per 1.73 m²) with decreasing function over time; eGFR trajectory 6: patients with low baseline eGFR (~40 mL/min per 1.73 m²) with stability over time; eGFR trajectory 7: patients with very low baseline eGFR (28 mL/min per 1.73 m²) and mildly declining function over time; and eGFR trajectory 8: patients with intermediate eGFR (58 mL/min per 1.73 m²) but a very fast subsequent decline in eGFR trajectory. Abbreviation: CKD, chronic kidney disease. Recreated with permission from Raynaud et al.

Figure 2.

Conceptual framework of conservative kidney management in kidney transplant. CKD; chronic kidney disease.

Figure 3.

Serious illness conversation guide for decision making with patients with poorly functioning and declining allografts.