Nephrology Care Research Articles

Feasibility and Acceptability of a Palliative Care Intervention Among Older or Adults with Advanced CKD and their Caregivers.

In non-nephrology settings, specialty Palliative Care (PC) improves decision-making, patient's quality of life (QoL), advance care planning (ACP), and certain indicators of the quality of end-of-life (EoL) care. This pilot RCT explored the feasibility and acceptability of a PC intervention, CKD-EDU, for older adults ≥75 years with eGFR ≤25 ml/min and their caregivers. Participants randomized to the control group received standard nephrology care and routine kidney therapy (KT) education, while those randomized to CKD-EDU received a decision aid and met with a PC clinician up to three times to discuss KT decisions and EoL planning. Patients were assessed at baseline, 4-6, 12-14, and 24-26 weeks. Main outcomes included intervention feasibility and acceptability, decision-conflict, and patient QoL. The mediating effects of reduced decision conflict on improved QOL were explored, as were the effects of CKD-EDU on ACP, EoL treatment intensity and 6-month-hospitalization. Statistical analyses encompassed descriptive analyses, adjusted repeated-measure-models, mediation analyses and logistic-regression models. Among the 127 eligible patients screened, 58 (44%) consented: 30 were randomized to CKD-EUD and 28 to the control arm. All patients completed baseline assessments, and 89% completed at least one intervention session (n=26/29), underscoring intervention adherence and feasibility. Similarly, assessments completion rates at 4 (83%, n=45/54) ), 12 (93%, n=42/45), and 24 (95%, n=40/42) weeks were high. The intervention received over 85% acceptability ratings for all questions. Patients exposed to CKD-EDU exhibited significant improvement in decisional conflict scale scores (P = 0.003) at 4-6 weeks and improvements in QoL at 24-26 weeks (P=0.02). Exploratory analyses were not statistically significant in this pilot, but all effect sizes were in the predicted direction. This study demonstrates the feasibility and acceptability of CKD-EDU. A larger scale trial is warranted to assess its effectiveness in improving key outcomes important to patients and families.

HGGL-01 GLIOBLASTOMA MULTIFORM INVOLVING MULTIPLE BRAIN REGIONS ASSOCIATED WITH MUTATIONS IN EXON 4 OF ISOCITRATE DEHYDROGENASE 1 COMPLICATED BY ACUTE KIDNEY FAILURE: A CASE REPORT

Abstract Glioblastoma multiform (GBM), WHO grade 4, is the most aggressive primary brain tumor in adults associated with poor prognosis. We present a case of a 43-year-old female, Muyira, diagnosed with GBM involving multiple brain regions and harboring mutations in exon 4 of isocitrate dehydrogenase 1, who subsequently developed acute kidney failure. The patient initially presented with progressive neurological symptoms, including headache and cognitive decline. Multiplanar multiecho MRI of the brain was performed with IV contrast in orthogonal plane and revealed a moderate sized multilobulated heterogeneously and predominantly peripherally enhancing mass lesion with irregular margins and central non enhancing areas of necrosis arising from the right corona radiata, insular cortex, external capsule, lentiform nucleus, temporal, and frontal white matter with blood products. Perilesional edema was seen. Effacement of sulcal spaces. Right sylvian fissure, compression over right ventricle and midline shift of 8mm toward left side. There was dilatation of the left lateral ventricle with periventricular cerebrospinal fluid ooze. Uncal herniation was right side. On MR spectroscopy large choline, creatinine levels were seen in the lesion with reduced N-acetyl aspartate levels as compared to the normal parenchyma. Findings were suggestive of neoplastic lesion mostly high-grade glioma. Polymerase chain reaction sequencing confirmed the presence of missense mutation R132H in exon 4 of isocitrate dehydrogenase 1 gene. Despite maximal safe surgical resection, the patient developed acute kidney failure secondary to the nephrotoxic effects of gadolinium. Management of both the primary brain tumor and renal complication necessitated a multidisciplinary approach involving neurosurgery, oncology, nephrology, and supportive care. Despite aggressive interventions, the patient’s condition deteriorated, highlighting the challenges in managing concurrent life-threatening conditions in patients with advanced GBM.

Facility-Level Variation in Nephrology Care among Veterans after Urinary Stone Events

Facility-Level Variation in Nephrology Care among Veterans after Urinary Stone Events

Advancing Nephrology Care Access for Veterans: Implementation and Insights from a Telenephrology Program

Advancing Nephrology Care Access for Veterans: Implementation and Insights from a Telenephrology Program

Enhancing Access to Nephrology Care: Development of a Telenephrology Dashboard via Human-Centered Design

Enhancing Access to Nephrology Care: Development of a Telenephrology Dashboard via Human-Centered Design

Impact of Predialysis Nephrology Care on Incident Vascular Access Outcome among Hispanic Individuals: A Causal Mediation Analysis

Impact of Predialysis Nephrology Care on Incident Vascular Access Outcome among Hispanic Individuals: A Causal Mediation Analysis

The impact of life events on child and adolescent psychiatry consultations

Purpose: Children are exposed to many adverse life events, and this may cause psychiatric disorders. In this study, we aimed to investigate the effects of two different life events, the COVID-19 pandemic and the earthquake, on the consultations requested. Materials and Methods: 1268 consultations requested from the child and adolescent psychiatry department between March 2019 and March 2023 were reviewed from hospital records. The specified period was divided into four distinct parts with one-year intervals: pre-pandemic, the first year of the pandemic, the second year of the pandemic, and post-pandemic. The age, gender, diagnoses of the cases, the department requesting consultation and the reason for consultation were recorded. Results: There were statistically significant differences between periods in terms of departments requested consultation, consultation reasons, and diagnoses. Compared to previous periods, a decrease was found in pediatric emergency and general pediatric clinic consultations in the post-pandemic period. In contrast, an increase was seen in nephrology and intensive care unit department consultations because of earthquakes. In the first year of the pandemic, more consultations were requested from the hematology & oncology department compared to other years. While the rate of consultations requested for suicide attempts decreased in the post-pandemic period, consultations for psychiatric assessment increased. Conclusion: Consultation-liaison psychiatry, which is at the center of interdisciplinary interaction, maintains its importance in the prevention and early diagnosis of psychological symptoms that can develop due to both organic events and the effect of trauma itself after the life events.

Transition of care from pediatric to adult nephrology post-renal transplant: a review.

Pediatric renal transplant recipients (RTRs) face heightened risks when they transition from a childhood nephrologist to an adult-centered one. The transition of care usually occurs when an individual is between ages 18 and 21 years, although some change providers earlier or later depending on varying circumstances. Turbulence during this shift can significantly impact daily life and, in severe cases, lead to graft loss. Several modern studies have explored the transition from pediatric to adult-centered nephrology care post-renal transplant. In this review, we first provide an overview of the differences between pediatric and adult renal transplant, highlighting unique challenges faced by pediatric patients such as donor-recipient size disparity, growth impairment, and need for additional immunizations. We then emphasize the criticality of a well-planned transition process, identifying factors that can hinder a smooth transition-such as medical and medication nonadherence, lack of health literacy, patient psychosocial challenges, and systemic shortcomings in coordination between care teams. Furthermore, this review outlines existing protocols and risk assessment tools, in addition to highlighting recent advancements aimed at facilitating smoother transitions such as the RISE protocol, readiness assessment, and the use of multidisciplinary teams. Proper implementation of coordinated, evidence-based transition protocols can improve patient outcomes, promote medication and appointment adherence, and reduce graft rejection rates. Efforts from multidisciplinary teams utilizing technology, risk stratification tools, and open communication between providers and patients are key to optimizing the transition process for pediatric RTRs as they transfer to adult-centered care.

First interim results from FINE-REAL: a prospective, non-interventional, phase 4 study providing insights into the use and safety of finerenone in a routine clinical setting.

Finerenone, a selective non-steroidal mineralocorticoid receptor antagonist, improves kidney and cardiovascular outcomes in patients with chronic kidney disease (CKD) associated with type 2 diabetes (T2D). The FINE-REAL study (NCT05348733) aims to evaluate the characteristics and treatment patterns of participants treated with finerenone in clinical practice. FINE-REAL is a prospective, single-arm, non-interventional study of patients initiated on finerenone as part of their routine care in accordance with country-approved labels. The study, initiated in June 2022, is expected to be completed by January 2028. The cutoff for this pre-specified interim analysis was June 13, 2023. Participants were recruited across nephrology, endocrinology, cardiology, and primary care settings. Of 556 participants enrolled in the study by the cut-off date, 504 were included in this analysis (median follow-up duration of 7months [finerenone treatment initiation to last recorded observation]). At baseline, 76.1% of participants were in the high or very high (KDIGO) CKD risk categories. Angiotensin converting enzyme inhibitors/angiotensin receptor blockers and sodium-glucose cotransporter 2 inhibitors were prescribed to 71.8% and 46.6% of participants, respectively. Based on prescribing information, 87.9% and 12.1% of participants initiated finerenone at doses of 10 and 20mg, respectively. Finerenone treatment was uninterrupted in 92.3% of participants after 7months' median follow-up. Treatment-emergent adverse events occurred in 110 (21.8%) participants. Hyperkalemia occurred in 25 (5.0%) participants, with no cases leading to death, dialysis, or hospitalization. At this interim analysis, finerenone was initiated in patients with CKD and T2D across various clinical practices participating in the study. Treatment discontinuation and hyperkalemia occurred infrequently.

Race- and Ethnicity-Related Disparities in Predialysis Nephrology Care, Kidney Disease Education, and Home Dialysis Utilization.

Pre-dialysis nephrology care and kidney replacement therapy (KRT)-directed education (KDE) are essential for incident home dialysis use. However, there are substantial disparities in these care parameters among patients with advanced CKD. The impact of these disparities on home dialysis underuse has not been examined. We analyzed the 2021 US Renal Database System to identify all adult kidney failure patients with over six months of pre-dialysis Medicare coverage initiating their first-ever dialysis between 2010 and 2019. We used a mediation analysis to dissect the attributable influence of disparities in pre-dialysis nephrology care and KDE on incident home dialysis use. Additionally, we conducted sensitivity analyses using graded levels of mediators and sustained impact on home dialysis outcomes. We identified 464,310 Medicare recipients: 428,301 using incenter hemodialysis and 35,416 using home dialysis as their first-ever dialysis modality during the study period. Compared to non-Hispanic White patients (n=294,914), adjusted odds ratio (95% confidence intervals) for receiving pre-dialysis nephrology care, KDE service, and incident home dialysis were 0.62(0.61, 0.64), 0.58(0.52, 0.63) and 0.76(0.73, 0.79) respectively among Hispanic individuals (n=49,734), and 0.74(0.73, 0.76), 0.84(0.79, 0.89), and 0.63(95%CI:0.61, 0.65) respectively among Black individuals (n=98,992). Mediation analyses showed that compared to non-Hispanic White individuals, lack of nephrology care explained 30% and 14% of incident home dialysis underuse among Hispanic and Black individuals, respectively (p<0.001). Sensitivity analyses using a longer duration of nephrology care and KDE services and the sustained impact on home dialysis underuse through the first-year post-kidney failure showed congruent and consolidating findings. Disparities in pre-dialysis nephrology care were significantly associated with lower home dialysis among Hispanic and Black individuals.

The Pattern of Practice in the Management of Early Diabetic Kidney Disease.

Background and objectives Diabetes is a leading cause of kidney failure in various regions worldwide. To detect renal disease in individuals with diabetes, screening typically involves evaluating the glomerular filtration rate and measuring albuminuria. Although there are established guidelines for these screenings, adherence to them varies. This study aims to examine the prevalence of albuminuria screening among adults with diabetes mellitus (DM) and to assess the different practices in managing these patients across primary and tertiary care settings. Methods This cross-sectional observational study involved adult patients with DM attending outpatient clinics in both primary and tertiary care settings. Patient data were gathered using a standardized form, excluding those with established chronic kidney disease (CKD) who were under nephrology care. Results The study included 1,010 patients, with 303 (30%) from primary care clinics and 707 (70%) from tertiary care clinics. The cohort comprised 582 (58%) females, with a median age of 62 years (IQR: 55-70), and approximately 990 (98%) had type 2 DM (T2DM). Annual albumin-to-creatinine ratio (ACR) screening was conducted for 498 out of 1,010 patients (49%) (95% confidence interval {CI}: 46%-52%). Screening compliance was notably higher in primary care settings compared to tertiary care clinics. Older patients (over 60 years) and those with hypertension or cardiac conditions were less likely to undergo screening. Among those screened, 185 of 498 patients (37%) (95% CI: 33%-41%) had abnormal albuminuria (ACR > 3). Conclusion Albuminuria is a significant indicator of progressing renal disease and cardiovascular risk. The annual screening rate for albuminuria in diabetic patients is inadequate. Primary care physicians show better adherence to screening guidelines compared to their tertiary care counterparts. Increasing physician awareness about the importance of screening could improve guideline compliance and mitigate the adverse effects of albuminuria.

ANEMIA PATTERN IN PATIENTS WITH CHRONIC KIDNEY DISEASES PRESENTED AT TERTIARY CARE HOSPITAL

Anemia is a common complication in patients with chronic kidney disease (CKD) and contributes significantly to morbidity. Understanding the patterns and severity of anemia within this population can guide more effective management strategies. Objective: To assess the pattern and severity of anemia in patients with chronic kidney disease. Methods: This cross-sectional study was conducted from January 2024 to July 2024, involving 250 anemic CKD patients aged 18 years and above. The study was carried out at a nephrology care facility, with participants selected based on predefined inclusion and exclusion criteria. Data on demographic information, laboratory profiles, and anemia patterns were collected. Anemia was classified into mild, moderate, and severe categories. Statistical analysis was performed using SPSS version 24 to establish associations between the severity of CKD and the type of anemia. Results: Among the patients, 59.2% had normochromic anemia, 18.8% had hypochromic anemia, and 14% had macrocytic anemia. Moderate anemia was the most prevalent severity, observed in 51.2% of cases, followed by mild anemia in 41.6% and severe anemia in 7.2%. A significant association was noted between the severity of CKD and the type of anemia, particularly with normochromic anemia being more prevalent in patients with moderate CKD. Conclusion: The study concludes that normochromic anemia is the most predominant pattern of anemia in CKD patients, followed by hypochromic and macrocytic anemia. These findings underscore the importance of regular monitoring and tailored anemia management in CKD patients to improve overall patient outcomes.

Integration of Primary Preventive Care of Cardiovascular Disease in a Retroviral Clinic in an adult retroviral clinic in Ibadan: A retrospective study.

A consequence of improved survival of people living with human immunodeficiency virus (HIV) (PLHIV) is an aging population with an increased risk of developing atherosclerotic cardiovascular diseases (ASCVDs). International guidelines recommend primary preventive strategies which should be integrated into routine care of PLHIV. This study audited the ASCVD preventive practices offered to PLHIV at the adult antiretroviral clinic in Ibadan. This was a retrospective review of clinical records of all persons who were recruited into the antiretroviral therapy clinic between January 1 and December 31, 2018. Cardiovascular disease (CVD) preventive practices were audited against recommendations of the American Heart Association for PLHIV. The records of 568 persons with a mean (standard deviation) age of 39.95 (11.77) years were reviewed. There were 365 (64.26%) females and 203 (35.74%) males. Only 364 (64.08%) patients had the required parameters for the calculation of the low-density lipoprotein cholesterol (LDL-C) by the Friedewald formula. Ten-year ASCVD risk was not calculated for any of the patients during their clinic visits. Thirty-seven (6.51%) patients had either an LDL-C ≥4.91 mmol/L or an age between 40 and 75 years with diabetes mellitus or ASCVD risk score (when calculated) ≥ 7.5%. Only one of these persons was referred for specialist care of lifestyle modification. Fifty (8.80%) persons had an eGFR <60 mLs/min, but only 11 (1.94%) were referred for nephrology care. The integration of primary preventive cardiovascular practices into routine care for PLHIV is suboptimal. A revision of the recommendations of the Nigerian National Guidelines for HIV may be a useful first step addressing this.

P.339: Retrospective analysis of nephrology care in the Republic of Azerbaijan: A single center experience.

P.339: Retrospective analysis of nephrology care in the Republic of Azerbaijan: A single center experience.

Towards an effective obstetric nephrology care: the Mansoura experience.

Towards an effective obstetric nephrology care: the Mansoura experience.

Comparing Nephrologists' Self-Reported Decision-Making Skills and Treatment Attitudes With Their Patients' Experiences of Making Kidney Therapy Decisions and Receiving Nephrology Care.

Dialysis is often initiated in the United States without exploring patients' preferred decision-making style, and conservative kidney management (CKM) is infrequently presented. To improve kidney therapy (KT) decision-making, research on nephrologists' comfort with various decision-making styles, attitudes towards CKM, and reports of patients' lived experiences with KT decision-making is needed. We surveyed 28 nephrologists and 58 of their patients aged ≥75years. The nephrologist survey was designed to gauge their comfort levels with decision-making styles and attitudes towards CKM. The patient survey assessed experiences in making KT decisions. The average age of nephrologists was 43years, and that of patients was 82years. Nephrologists rated themselves as comfortable with various decision styles: paternalistic (60.7%), shared decision-making (92.8%), and patient-driven decision-making (67.8%). Nearly 57% of nephrologists felt challenged or were neutral in determining CKM's suitability, and 39% reported difficulties in discussing CKM with patients or were neutral. Only 38 % of patients recalled discussing CKM with their nephrologists, and a minority reported discussing CKM-related topics such as life expectancy (24.7%), quality of life (QOL) (45.1%), and end-of-life care (17.5%). Most nephrologists displayed comfort with various decision-making styles; however, many described difficulties in guiding patients toward CKM. In contrast, patients reported gaps in vital aspects of KT decision-making and CKM choices, such as discussions of life expectancy, QOL, and end-of-life care. Raising awareness of blind spots in decision-making skills and educating nephrologists in KT decision-making to include CKM and other person-centered aspects of care are needed.

The burden of hyperkalaemia on hospital healthcare resources

Hyperkalaemia is associated with prolonged hospital admission and worse mortality. Hyperkalaemia may also necessitate clinical consults, therapies for hyperkalaemia and high-dependency bed utilisation. We evaluated the ‘hidden’ human and organisational resource utilisation for hyperkalaemia in hospitalised patients. This was a single-centre, observational cohort study (Jan 2017–Dec 2020) at a tertiary-care hospital. The CogStack system (data processing and analytics platform) was used to search unstructured and structured data from individual patient records. Association between potassium and death was modelled using cubic spline regression, adjusted for age, sex, and comorbidities. Cox proportional hazards estimated the hazard of death compared with normokalaemia (3.5–5.0 mmol/l). 129,172 patients had potassium measurements in the emergency department. Incidence of hyperkalaemia was 85.7 per 1000. There were 49,011 emergency admissions. Potassium > 6.5 mmol/L had 3.9-fold worse in-hospital mortality than normokalaemia. Chronic kidney disease was present in 21% with potassium 5–5.5 mmol/L and 54% with potassium > 6.5 mmol/L. For diabetes, it was 20% and 32%, respectively. Of those with potassium > 6.5 mmol/L, 29% had nephrology review, and 13% critical care review; in this group 22% transferred to renal wards and 8% to the critical care unit. Dialysis was used in 39% of those with peak potassium > 6.5 mmol/L. Admission hyperkalaemia and hypokalaemia were independently associated with reduced likelihood of hospital discharge. Hyperkalaemia is associated with greater in-hospital mortality and reduced likelihood of hospital discharge. It necessitated significant utilisation of nephrology and critical care consultations and greater likelihood of patient transfer to renal and critical care.

Symptom Burden and Its Impact on Quality of Life in Patients With Moderate to Severe CKD: The International Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps)

Recent evidence suggests people with nondialysis chronic kidney disease (ND-CKD) experience a substantial burden of symptoms, but informative large-scale studies have been scarce. We assessed the prevalence of symptoms and the association of overall symptom burden with quality of life in patients with moderate to severe CKD. Cross-sectional study. 4,430 patients with ND-CKD stages 3-5 enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) in Brazil, France, and the United States between 2013 and2021. 13 individual patient-reported symptoms from the Kidney Disease Quality of Life Short Form (KDQOL-SF) questionnaire and an overall symptom burden score (low, intermediate, and high). Physical and mental component summary scores (PCS and MCS) of the KDQOL-SF. Adjusted prevalence ratios and generalized estimating equations. Patients (mean age, 68 years; 40% women; mean baseline estimated glomerular filtration rate [eGFR], 30mL/min/1.73m2) were very much to extremely bothered by numerous symptoms ("soreness in muscles," 23%; "washed out or drained," 21%; "cramps, shortness of breath, dry skin, diminished sex life, or numbness in hands or feet," 14%-17%). The adjusted prevalences of "cramps," "washed out or drained," "lack of appetite," "nausea/upset stomach," and "sex life" were greater with more severe CKD and in women (except for "sex life"). A high overall symptom burden was more common in women, in France, and in patients with severe albuminuria and various comorbidities, but not with lower eGFR. The PCS and MCS scores were 13.4 and 7.7 points lower, respectively, for high versus low overall symptom burden. Generalizability limited to patients under nephrology care, residual confounding, and inaccurate Brazilian translation of some symptoms. The high symptom burden observed in this large cohort of ND-CKD patients across 3 diverse countries and its strong association with poorer health-related quality of life should inform clinical management of and clinical research in CKD. Little is known about symptoms in patients with non-dialysis-dependent chronic kidney disease (ND-CKD). In the Chronic Kidney Disease Outcomes and Practice Patterns Study, which enrolled 4,430 patients with CKD stages 3-5 in Brazil, France, and the United States, patients most often reported soreness in muscles, feeling washed out or drained, cramps, shortness of breath, dry skin, altered sex life, and numbness in hands or feet. Cramps, feeling washed out or drained, lack of appetite, and nausea were more often reported at lower levels of kidney function. The overall symptom burden was higher in women than men, in French than in Brazilian or US patients, and in those with severe albuminuria. The higher the symptom burden, the lower were the physical and mental health quality of life scores. The high symptom burden observed in this large cohort of ND-CKD patients across 3 diverse countries and its strong association with poorer health-related quality of life should inform clinical management of and clinical research in CKD.

Clinical Outcomes of a Novel Multidisciplinary Care Program in Advanced Kidney Disease (PEAK)

IntroductionMulti-disciplinary care (MDC) for late-stage chronic kidney disease (CKD) has been associated with improved patient outcomes compared with traditional nephrology care, but the optimal MDC model is unknown. In 2015, we implemented a novel MDC model for patients with late-stage CKD informed by the Chronic Care Model conceptual framework, including an expanded MDC team, care plan meetings, clinical risk prediction, and a patient dashboard. MethodsWe conducted a single-center, retrospective cohort study of adults with late-stage CKD (estimated glomerular filtration rate [eGFR] < 30 mL/min per 1.73m2) enrolled from May 2015 to February 2020 in the Program for Education in Advanced Kidney disease (PEAK). Our primary composite outcome was an optimal transition to end-stage kidney disease (ESKD) defined as starting in-center hemodialysis (ICHD) as an outpatient with an arteriovenous fistula (AVF) or graft (AVG), or receiving home dialysis, or a pre-emptive kidney transplant. Secondary outcomes included home dialysis initiation, pre-emptive transplantation, vascular access at dialysis initiation, and location of ICHD initiation. We used logistic regression to examine trends in outcomes. Results were stratified by race, ethnicity, and insurance payor and compared with national and regional averages from the United States Renal Data System (USRDS) averaged from 2015 to 2019. ResultsAmong 489 patients in the PEAK program, 37 (8%) died prior to ESKD and 151 (31%) never progressed to ESKD. Of the 301 (62%) patients who progressed to ESKD, 175 (58%) achieved an optimal transition to ESKD, including 54 (18%) peritoneal dialysis, 16 (5%) home hemodialysis, and 36 (12%) preemptive transplant. Of the 195 (65%) patients starting ICHD, 51% started with an AVF or AVG and 52% started as an outpatient. The likelihood of starting home dialysis increased by 1.34 times per year from 2015 to 2020 (95% CI 1.05 – 1.71, p = 0.018) in multivariable adjusted results. Optimal transitions to ESKD and home dialysis rates were higher than national USRDS data (58% vs. 30%; 23% vs. 11%) across patient race, ethnicity, and payor. ConclusionsPatients enrolled in a novel comprehensive MDC model coupled with risk prediction and health information technology were nearly twice as likely to achieve an optimal transition to ESKD and start dialysis at home, compared with national averages.

Understanding and addressing symptoms for those with kidney failure managed conservatively, without dialysis: considerations and models of care.

For those who have kidney failure and are managed conservatively without dialysis, symptoms are often prevalent, multiple, and troublesome. They interfere with quality of life, reduce wellbeing, and can affect family carers too. Symptoms can sometimes be difficult to manage, and-for professionals-they are often hard to assess and not always amenable to management with medications appropriate for use in kidney failure. Fatigue is one of the most common symptoms; alongside a general overview of symptoms in this population, we include a more detailed discussion of this often-neglected symptom. The solutions to the main symptoms experienced by those with kidney failure managed conservatively without dialysis lie in detailed assessment and monitoring of symptoms, working as a multi-disciplinary team to the maximum to draw on the full range of skills and expertise, and use of non-pharmacological, as well as pharmacological, approaches. Both nephrology and palliative care skills and expertise are important to optimise the recognition, assessment, and management of symptoms. There are few published descriptions of models of conservative kidney management (CKM) or supportive kidney care and there is a lack of evidence to suggest which model is most effective. We therefore consider the evidence on optimal models of CKM and make suggestions for best practice.