Dialysis and Kidney Transplantation — Three Sieves That Stand In, and the Path That Uses None

"It is time to prepare for dialysis"

In the examination room where he has brought his seventy-eight-year-old mother, the doctor says, "It is time to prepare for dialysis." His mother has taken medication for a long time for diabetes and heart disease, and lately she says she tires easily and has no appetite. Questions flood all at once into the mind of the child who came along. Must dialysis be done for life? How often must one go to the hospital? Is a transplant not possible? Must it really be done at this age?

The doctor's words mean that the mother's kidneys can barely work anymore, and that they should prepare for a treatment to take over that work. Dialysis is a treatment that filters out waste products from the blood and excess water outside the body through a machine or inside the body through a membrane, instead of the kidneys. The kidneys are bean-shaped organs, one on each side in the lower back above the waist, that filter the blood and send out waste products and excess water as urine.

This article follows those questions one by one. What replaces the work the kidneys used to do, how machine dialysis, dialysis inside the belly, and transplanting a new kidney differ in daily life and outcomes, when it begins, and what the path of caring for symptoms without doing dialysis is. The evidence comes from reviews and guidelines that gather studies from multiple countries.

When the Kidneys Can Barely Do Their Job

Chronic kidney disease is a state where the kidneys are damaged or their function has declined for more than three months. It is estimated that about 850 million people have this disease worldwide, and among them, about 4 million people have lost their kidney function to the point where they need dialysis or a transplant (PMID 41314225). Most people with this disease develop disabilities or die from heart and blood vessel diseases before their kidney function bottoms out (PMID 41314225). This means a diagnosis of chronic kidney disease does not immediately mean dialysis. Since 2019, large-scale trials have identified several treatments that slow down the rate at which kidney function declines while also lowering heart and blood vessel risks (PMID 41314225). The stages of this disease and how to slow its progression are followed in "What Is Chronic Kidney Disease? — Lamps Going Out One by One, and the Load on Those Still Lit".

Kidney failure is a state where kidney function has dropped significantly, to the point where the kidneys alone can no longer handle the body's waste products and excess water. It corresponds to the heaviest stage of chronic kidney disease, and is also called end-stage kidney disease. During this period, there are many symptoms. Common ones are pain, fatigue, trouble sleeping, itching, loss of appetite, and nausea (PMID 26709063). Your mother easily tiring and saying she has no appetite also falls within this list. These symptoms appear to increase as the disease deepens, and that review noted that one must prepare for them in advance (PMID 26709063).

A review addressing the choices of older people broadly divides the path when kidney function bottoms out into three. Transplantation is a path to extend life while maintaining a good quality of life, dialysis is a path that places weight on extending life, and conservative care without dialysis or a transplant is a path that puts quality of life ahead of extending life (PMID 41143833). Since dialysis has two types, the paths become four in total.

Laying these four against a sieve makes things clear. The kidneys are a sieve that filters blood without resting. When that sieve nearly stops, another sieve can be substituted. One dialysis uses the sieve of a machine outside the body, the other dialysis uses the membrane inside my belly as a sieve, and a transplant puts in a new sieve received from another person. The fourth path cares for the person, sparing the remaining sieve without substituting a new one.

This analogy captures only the filtering work. The kidneys do many jobs besides filtering, such as regulating blood pressure and sending signals to make red blood cells in the body, and those jobs are in "How Do the Kidneys Filter Blood? — A Sieve That Takes Almost Everything Back". Also, while my kidneys filter all day long, hemodialysis filters in a concentrated manner at set times. The substituted working sieves are three, the fourth path is the path without substituting a sieve, and these four differ from each other in daily life and outcomes.

The First Sieve — Hemodialysis by Machine

Hemodialysis is a treatment where blood drawn from a blood vessels is passed through a filter inside a machine to filter out waste products and excess water, and then returned to the body. People usually go to a dialysis clinic on set days of the week and receive treatment while connected to a machine for several hours.

Doing this requires a site that can draw and return a generous amount of blood. A vascular access is a pathway created in advance so that enough blood can be drawn and returned during each hemodialysis session. An arteriovenous fistula is created by surgically connecting an artery and a vein in the arm, using the resulting thick and sturdy vein as the vascular access. An access can also be made by connecting a synthetic graft, or by placing a tube into a large vein in the neck or chest. People who start dialysis with an arteriovenous fistula or a synthetic graft are associated with fewer infections, deaths, and hospitalizations, as well as lower costs, compared to those who start with a tube placed in a vein (PMID 37579517). This is why having a vascular access prepared in advance is part of the preparation if one is likely to need hemodialysis. The story that this preparation also has a price comes in the section on the timing of initiation.

Hemodialysis can also be done at home. After receiving training and bringing in a machine, it can be done daily, every other day, or while sleeping at night, with session lengths ranging from under 3 hours during the day to 6 to 10 hours at night (PMID 36754523). While there are data supporting the hypothesis that more frequent and longer dialysis improves survival, heart and blood vessel risks, and quality of life, controlled trials are few and most are registry data, and the time required for training and the risk of burnout are noted as drawbacks (PMID 36754523). The authors of that review considered these limitations surmountable in advance through thorough training and multidisciplinary management (PMID 36754523).

The rhythm of dialysis stays in the body. Fatigue lasting for several hours after dialysis ends is common, and the proportion of people experiencing this fatigue varies from 20% to 86% across studies, likely because the measurement methods and participants differed from one another (PMID 37187283). Managing the water and blood pressure that accumulate in the body between dialysis sessions is a matter of carefully weighing multiple risks alongside the patient's lifestyle and preferences within a narrow margin (PMID 32278617). Hemodialysis is a path where a machine becomes the sieve, and it begins with deciding whether to prepare the vascular access connecting that sieve to the body in advance.

The Second Sieve — Peritoneal Dialysis, Filtering Through the Membrane Inside My Belly

The peritoneum is a thin membrane that lines the inner wall of the belly and the outside of the organs. Peritoneal dialysis is a treatment that filters out waste products and excess water from the blood by filling and draining a dialysis solution through a tube placed in the belly, using the peritoneum as a filter. The peritoneum must function healthily to remove enough excess water to restore the body's water balance (PMID 37616463).

Peritoneal dialysis is a treatment done at home. There is a method of manually filling and draining the dialysis solution, and a method of connecting a tube to a machine to change it automatically according to a set schedule (PMID 39258519). Which of the two methods is better has been compared in only two trials divided by a lottery, involving a total of just 131 people, which is not enough evidence to serve as a medical guide (PMID 39258519).

11% of dialysis worldwide is peritoneal dialysis, and it is available in 81% of countries, but that rate is split between 96% in high-income countries and 32% in low-income countries (PMID 36114414). Compared to hemodialysis, its potential advantages include simpler technology, ease of travel, fewer dietary restrictions, high treatment satisfaction, and better preservation of remaining kidney function (PMID 36114414).

Residual kidney function is the filtering power remaining in one's kidneys even after starting dialysis. There is evidence that peritoneal dialysis can reduce the risk of losing this power compared to hemodialysis, but the certainty is low (PMID 38899545).

Many people do not stick with the first sieve they choose all the way through. Up to 35% of people receiving peritoneal dialysis switch to in-center hemodialysis each year, and the reasons span evenly across problems with patients, caregivers, the healthcare system, and peritoneal dialysis itself, with ongoing efforts to reduce these causes and help people continue peritoneal dialysis longer (PMID 30480532). Peritoneal dialysis is a path of filtering at home through the membrane inside my belly, and many people switch away from it.

Comparing the Two Types of Dialysis

Which dialysis to receive is chosen based on each person's individual circumstances. Therefore, comparisons between the two types of dialysis mostly come from observational studies. Observational studies are research where people's lives are not interfered with, and they are left to live as they normally do while watching what happens afterward. The differences seen in such studies can be confounded by differences between the people that existed from the beginning (PMID 38899545).

In a 2024 systematic review pooling 84 studies, there were only 2 trials that divided participants by drawing lots. The authors concluded that the differences between the two types of dialysis are uncertain in patient-centered outcomes such as remaining kidney function, death, bloodstream infections, vascular complications like stroke, and life participation (PMID 38899545). When just those 2 trials with 1,120 people were pooled separately, the results showed that the risk of death could be lower on the peritoneal dialysis side with moderate certainty, but there are only two trials (PMID 38899545).

When looking only at older adults, a different picture emerges. In an analysis pooling 31 observational studies involving roughly 774,000 older adults, the risk of death on the peritoneal dialysis side was about 1.17 times that of the hemodialysis side, and that difference was prominent in people who had been on dialysis for more than 3 years with diabetes or other illnesses, or who started dialysis before 2010 (PMID 38325351). The authors wrote that it is difficult to draw a definitive conclusion because the differences between the studies were large, and added that caution is needed when using peritoneal dialysis for a long time in such older adults, but that choices should be made by considering what matters to each individual older person (PMID 38325351).

In quality of life scores, the peritoneal dialysis side was higher in several domains. This was the result of pooling 21 studies involving 29,000 people, and the average age of the participants was 48 years old (PMID 32552800). Neither of the two types of dialysis has been established as better for everyone by current evidence, and a person's body and lifestyle become the criteria for choosing.

The Third Sieve — Transplantation of a New Kidney

Kidney transplantation is a treatment in which a kidney from another person is surgically implanted to take over the filtering work. The kidney may come from a deceased donor or a living donor. Living donation is when a living person gives up one of their two kidneys.

A systematic review summarizing 110 observational studies and some 1,920,000 participants published up to 2010 reported that in most studies, the risk of death was markedly lower in transplant recipients than in patients who continued dialysis (PMID 21883901). The risk of cardiovascular events was also lower in most studies, and quality of life was distinctly and substantially better (PMID 21883901). Even though the age and concurrent illnesses of transplant recipients increased over time, the relative advantage of transplantation appeared to grow rather than shrink (PMID 21883901). Because the observational studies were deemed too heterogeneous to pool their results into a single calculated estimate, the authors concluded that these findings support efforts to expand access to transplantation (PMID 21883901).

Although not explicitly listed as a limitation in the abstract of this review, the nature of observational studies seen in the previous section applies equally to this comparison. People who were able to receive a transplant and those who were not may have differed in health status from the outset, and those differences could be mixed into the results.

There are also differences in how the body feels. In an analysis pooling 449 studies from various countries, looking only at studies that measured fatigue, about 7 in 10 people experienced fatigue whether they were on dialysis or were chronic kidney disease patients not on dialysis or transplantation (PMID 35385471). In the transplanted group, fatigue, depression, itching, difficulty moving, sleep disturbance, and dry mouth were less common or less severe, and the authors cautiously noted that this may mean those symptoms stem from kidney disease (PMID 35385471). Quality of life scores were generally lower in the dialysis group than in the other groups (PMID 35385471).

A new sieve comes with management. Rejection is a reaction in which the body's immune system recognizes the transplanted kidney as foreign and attacks it. Immunosuppressants are drugs that suppress the power of the immune system to prevent rejection. Current immunosuppressants have greatly reduced acute rejection, but their ability to help the transplanted kidney last for a long time is still not fully satisfactory (PMID 40142628). If the transplanted kidney loses function, patients sometimes return to dialysis (PMID 39871717).

This path is not open to everyone. Available kidneys fall short compared to the number of people waiting for a transplant (PMID 40142628). Older individuals are frequently ineligible for transplantation (PMID 41143833). While the path to transplantation has also widened for people whose blood types or bodily antibodies do not match, an article outlining the situation in the United States noted that all candidates should receive a realistic, individualized estimate of how long they will wait (PMID 31255336).

The donor's share also enters the decision. The 2017 living donation guidelines from Kidney Disease: Improving Global Outcomes (KDIGO) suggested evaluating risk by looking at a candidate donor's age and health status all at once instead of judging by individual risk factors, while also noting the limitation of a lack of definitive long-term follow-up studies (PMID 28742762). In particular, the long-term safety of young donors is cited as a real concern in the field of transplantation (PMID 32229773). Although transplantation is a path superior in survival and quality of life in observational studies, the availability of a kidney and the recipient's physical condition open and close this path.

When to Start

Over the past few decades, the range of people who can receive dialysis has expanded greatly, significantly increasing the number of older, frail, and multimorbid individuals receiving dialysis, and advancing the timing of when dialysis starts (PMID 25343175). A 2014 review on end-of-life care noted that this broader and more intensive treatment trend is not backed by solid data, and suggested that for such patients who choose dialysis, delaying the start until symptoms appear may be reasonable (PMID 25343175).

Apart from the timing, how well the start was prepared is also linked to outcomes. In an analysis of 27 studies, unplanned and urgent peritoneal dialysis was associated with more mechanical problems, such as dialysis fluid leaks, and higher mortality compared to planned starts (PMID 38477178). The authors concluded that careful planning is needed when starting peritoneal dialysis (PMID 38477178).

Creating a vascular access in advance is also part of preparation. Starting with a pre-formed access is linked to the good outcomes seen in the previous section, but for older adults or those with other severe illnesses, that surgery can turn out to be unnecessary. This is because the kidney disease might ultimately not get worse, they might pass away before dialysis becomes necessary, or they might choose a path without dialysis instead of dialysis (PMID 37579517).

When to start dialysis in acute kidney injury, where the kidneys suddenly do less work over a few days, is a separate issue that has been debated for decades (PMID 36100262). That story is followed by "What Is Acute Kidney Injury? — A Tap That Suddenly Runs Dry, and Three Places to Look". The time to start dialysis is decided together by symptoms, time to prepare, and the path the person has chosen.

The Road Without Dialysis — Conservative Kidney Management

Among people starting dialysis for the first time in the United States, the fastest-growing group is older adults (PMID 41143833). For many who are not candidates for a transplant, dialysis is often presented as the default, and many older patients report that they were not informed of all their options (PMID 41143833). Because older adults often prioritize quality of life over extending life, the default may conflict with the person's goals (PMID 41143833).

Conservative kidney management is care that avoids dialysis and transplantation while preserving remaining kidney function, easing symptoms and complications, and putting quality of life first. Treatment continues on this path as well. It prevents remaining kidney function from worsening further, eases symptoms and complications that arise as the disease progresses, and cares for the physical, mental, and spiritual well-being of both patients and their families (PMID 40308407).

There are people for whom this path is frequently discussed. Frailty is a state in which physical and cognitive strength decline together, marked by weight loss, easy exhaustion, reduced movement, weaker muscles, and slower walking. Frailty is common in people receiving dialysis, and frail individuals have a lower quality of life, a higher risk of hospitalization, infection, and death, and there is no treatment that cures frailty (PMID 38705274). However, the same review noted that monitoring nutrition, reducing medications, tailoring dialysis to the individual, or considering home-assisted dialysis can slow the rate of physical decline (PMID 38705274). A 2016 review noted that conservative management is a justifiable option for frail older adults in whom dialysis may not improve quality of life or length of life, and stated that decisions should be made after patients and families receive information about the future course, life on dialysis, and symptom care (PMID 26709063).

What about evidence comparing survival? A 2025 systematic review gathered 24 studies involving 26,127 kidney failure patients aged 65 and older, but not a single trial used random assignment (PMID 41363177). The two groups differed significantly from the start in conditions that affect future outcomes, and because these differences could not be fully adjusted for, the certainty of the evidence was "very low" (PMID 41363177). Among them, pooling 23 studies with 24,628 people comparing deaths showed 813 deaths per 1,000 people in the conservative management group versus 630 per 1,000 in the dialysis group, but the authors described the effect of conservative management on death as "uncertain" (PMID 41363177). The abstract does not specify how many years this figure represents. Differences in quality-of-life scores were also uncertain, and the authors concluded that the effect of conservative management compared with dialysis on death, hospitalization, and quality of life is uncertain (PMID 41363177).

An earlier 2014 review summarized that several researchers found conservative management could provide similar survival and better quality of life for some high-risk patients, and stated that palliative care and conservative management are underutilized despite being appropriate for some dialysis patients (PMID 25343175). Whether dialysis helps older people live longer, or whether survival is similar without dialysis, is not definitively established either way by current evidence. The position of the same 2016 review is that care to relieve symptoms is necessary not only for those who choose conservative management, but for everyone undergoing dialysis as well (PMID 26709063).

Choosing Together

There is a name for the way of deciding which path to take. Shared decision-making is the process in which clinicians and patients place the best evidence and the patient's goals and prognosis side by side, weigh the pros and cons of each treatment together, and decide on a treatment plan. This process helps patients make decisions that fit their own goals after thinking it through fully (PMID 41143833). For someone who is not sure, a trial of dialysis for a set period followed by re-evaluation can be used, and for someone who wants to keep their current state as is, the method of continuing the present state and "deciding not to decide yet" can be used (PMID 41143833). Within kidney disease care, a field is growing that helps patients whose remaining time might not be long due to severe illness or advanced age make such decisions (PMID 37579517).

Applying these four options back to the mother in the clinic, each path comes with its own evidence and limitations. Older people are often not candidates for transplantation (PMID 41143833), but whether the mother falls into that category will be discussed separately in the clinic. For hemodialysis, when to create a vascular access is the first question. Starting with a pre-created access is associated with better outcomes, but one also hears in the same setting that for people whose survival benefit from dialysis is reduced due to age or other serious illnesses, that surgery can be a pointless one (PMID 37579517). Peritoneal dialysis is a path that can be done at home. In observational studies involving older people, the risk of death was higher on the peritoneal dialysis side, but that difference was prominent only in certain subgroups such as those who had been on dialysis for a long time or started before 2010, and because the differences between studies were large, the authors could not draw definitive conclusions (PMID 38325351). If it is conservative management, symptom care follows. In studies comparing dialysis and conservative management, there were more deaths on the conservative management side, but the two groups had different conditions from the start, and the certainty of the evidence was "very low," so the authors stated that the effect is uncertain (PMID 41363177). If you cannot decide, there is time-limited dialysis (PMID 41143833).

On any path, the fatigue and lack of appetite the mother mentioned are symptoms that need to be addressed (PMID 26709063). If she were a 50-year-old father with no other major illnesses, the starting point that "older people are often not candidates for transplantation" would change, but the fact that he would need to be informed separately about how long he would have to wait because kidneys fall short compared to the number of people waiting remains the same (PMID 40142628; PMID 31255336). If a sibling steps forward to donate a kidney at that time, that sibling's risk is also weighed separately in light of their overall health status, and they will hear together about the limitation that long-term follow-up data are lacking (PMID 28742762). Which path is right is decided by placing what the person wants to protect most and their future course side by side with the medical team.

Where Else to Look

Trials assigned by a lottery-style draw and compared totaled only two between two dialyses, and not a single one between conservative care and dialysis. These are the findings found by reviews pooling studies up to 2024 and 2025, respectively (PMID 38899545; PMID 41363177). This is why many sentences in this article end with "association" and "uncertainty."

What the kidneys filter and what else they do is explained from the start in "How Do the Kidneys Filter Blood? — A Sieve That Takes Almost Everything Back". What creatinine and eGFR on a test result report measure is covered by "Reading Your Kidney Test Results — A Sieve You Cannot See, What Stays Behind and What Leaks Through", the long stretch of time before kidney function bottoms out and how to slow its progression by "What Is Chronic Kidney Disease? — Lamps Going Out One by One, and the Load on Those Still Lit", and when kidneys suddenly do less work over the span of a few days by "What Acute Kidney Injury? — A Tap That Suddenly Runs Dry, and Three Places to Look".

What the chronic disease your mother suffered from is can be seen in "What Is Diabetes? — The Letter That Never Comes, the Letter That Isn't Read". What blood pressure measures is found in "What Blood Pressure Measures — Two Numbers, and an Answer That Changes With Where You Measure".

What numbers like "813 per 1,000 versus 630 per 1,000" count is in "If the Risk Was Cut in Half, How Many Fewer People Got Sick? — Relative and Absolute Risk". However, because these numbers compared two different groups from the outset, that difference cannot be read directly as "dialysis lets so many more people live." Why numbers like remaining kidney function and the outcomes people actually feel are measured separately is covered by "Better Numbers, Better Patients? — An Introduction to Surrogate Endpoints".

Source Papers

• "Chronic kidney disease." (2026) — PMID 41314225 — Approximately 850 million people worldwide have chronic kidney disease, about 4 million need replacement therapy for kidney failure, most experience disability or death from cardiovascular disease before reaching kidney failure, and since 2019 many treatments have been confirmed to lower both progression and cardiovascular risk.
• "Conservative Care of the Elderly CKD Patient: A Practical Guide." (2016) — PMID 26709063 — Conservative management is a legitimate choice for frail older adults in whom dialysis may not improve the quality or length of life, common symptoms (pain, fatigue, insomnia, itching, loss of appetite, nausea) increase as death approaches, information on prognosis, dialysis life, and supportive care should be provided before deciding, and supportive care applies to both conservative and dialysis patients.
• "Supporting Shared Decision-Making in Life-Altering Kidney Therapy Decisions for Older Adults: A Review." (2025) — PMID 41143833 — Older adults are the fastest-growing population starting dialysis in the US, many are ineligible for transplantation making dialysis the default, many older adults do not receive guidance on all options, differences in goals among transplantation, dialysis, and conservative management, shared decision-making, time-limited trials of dialysis and choosing not to choose.
• "Dialysis Access Considerations in Kidney Palliative Care." (2023) — PMID 37579517 — Starting with an arteriovenous fistula or graft is associated with reduced infection, death, hospitalization, and cost compared with a central venous catheter, in older or severely ill patients a pre-created access can become an unnecessary surgery, and the role of kidney palliative care.
• "Clinical benefits of home hemodialysis and barriers to its development." (2022, French original, Nephrol Ther) — PMID 36754523 — Home hemodialysis is daily, alternate-night, or nocturnal, sessions range from under 3 hours to 6 to 10 hours at night, a hypothesis that increased frequency and time are associated with improvements in survival, cardiovascular health, and quality of life is supported by a small number of controlled studies and registry data, with training time and burnout risk as disadvantages.
• "Fatigue in Patients Receiving Maintenance Hemodialysis: A Review." (2023) — PMID 37187283 — Post-dialysis fatigue has a prevalence of 20 to 86% (varying by measurement method and participants), with a lack of mechanistic evidence.
• "Blood pressure and volume management in dialysis: conclusions from a KDIGO Controversies Conference." (2020) — PMID 32278617 — Blood pressure and fluid management in dialysis weigh various risks and patient life and preferences within a narrow therapeutic window, with individualized prescriptions.
• "The Peritoneal Membrane and Its Role in Peritoneal Dialysis." (2024) — PMID 37616463 — A healthy peritoneal membrane is the key to sufficient fluid removal and restoring fluid balance.
• "Automated peritoneal dialysis versus continuous ambulatory peritoneal dialysis for people with kidney failure." (2024) — PMID 39258519 — Peritoneal dialysis is home treatment, with manual (CAPD) and automated (APD) methods, and evidence from 2 RCTs with 131 participants is insufficient to choose between the two.
• "Epidemiology of peritoneal dialysis outcomes." (2022) — PMID 36114414 — Peritoneal dialysis accounts for 11% of dialysis worldwide and is available in 81% of countries (96% of high-income and 32% of low-income), with a list of potential advantages (simple technique, travel, fewer dietary restrictions, satisfaction, preservation of residual function, etc.).
• "Peritoneal dialysis versus haemodialysis for people commencing dialysis." (2024) — PMID 38899545 — 84 studies (2 RCTs, 82 non-randomized), possible reduction in the risk of losing residual function (low certainty), most outcomes such as death are uncertain, pooling only RCTs suggests a possible reduction in mortality (2 trials, 1,120 participants, moderate certainty), and the authors conclude that comparative effectiveness is uncertain.
• "Prevention of Peritoneal Dialysis Drop-Out." (2018) — PMID 30480532 — As many as 35% of peritoneal dialysis patients switch to in-center hemodialysis each year, caused by the patient, caregiver, system, or peritoneal dialysis itself.
• "Mortality of Peritoneal Dialysis versus Hemodialysis in Older Adults: An Updated Systematic Review and Meta-Analysis." (2024) — PMID 38325351 — 31 observational studies of about 774,000 older adults, peritoneal dialysis mortality hazard ratio 1.17, pronounced in diabetes, comorbidities, duration over 3 years, and starting before 2010, with high heterogeneity limiting definitive conclusions, and choices considering what matters to the individual.
• "Comparisons of quality of life between patients underwent peritoneal dialysis and hemodialysis: a systematic review and meta-analysis." (2020) — PMID 32552800 — 21 studies with 29,000 participants (average 48.1 years), peritoneal dialysis showed higher scores in some general and disease-specific quality of life domains.
• "Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes." (2011) — PMID 21883901 — 110 cohort studies of about 1.92 million people up to 2010, mostly lower mortality and cardiovascular risk and significantly better quality of life with transplantation, relative benefits increase over time, not pooled due to heterogeneity, supporting efforts to expand transplantation.
• "Symptom burden and health-related quality of life in chronic kidney disease: A global systematic review and meta-analysis." (2022) — PMID 35385471 — 449 studies with about 200,000 people, fatigue is 70% in both pre-dialysis and dialysis, fatigue, depression, itching, mobility issues, sleep problems, and dry mouth are less frequent after transplantation, and dialysis has lower quality of life scores.
• "Maintenance Immunosuppression in Kidney Transplantation: A Review of the Current Status and Future Directions." (2025) — PMID 40142628 — Transplantation is the standard treatment with better survival and quality of life than dialysis, there is a gap between organ supply and demand, and while immunosuppression has greatly reduced acute rejection, long-term transplant kidney survival remains inadequate.
• "Peritoneal dialysis and kidney transplantation: Your questions answered." (2025) — PMID 39871717 — The relationship between peritoneal dialysis and transplantation, including the use of peritoneal dialysis after transplant kidney function loss.
• "Transplanting the Untransplantable." (2020) — PMID 31255336 — Expanded options for candidates with blood type or antibody incompatibilities (US), and all candidates should receive individualized and realistic counseling on expected wait times.
• "KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors." (2017) — PMID 28742762 — Risk assessment combining donor candidate characteristics instead of a single risk factor, limited by a lack of definitive prospective studies and outcome trials.
• "Living Kidney Donor Evaluation." (2020) — PMID 32229773 — Long-term safety, especially of young donors, is a real concern in the transplant community, with inconsistent criteria across guidelines.
• "End-of-life matters in chronic renal failure." (2014) — PMID 25343175 — Expanding dialysis targets and earlier starts lack robust data to support this trend, delaying initiation until symptoms appear may be reasonable, conservative management may offer similar survival and better quality of life in some high-risk groups, and palliative and conservative care are appropriate but underutilized.
• "Comparison of Unplanned/Urgent-Start Versus Conventional-Start Peritoneal Dialysis: A Systematic Review and Meta-Analysis." (2024) — PMID 38477178 — 27 studies, urgently started peritoneal dialysis is associated with increased mechanical complications (leaks) and mortality, infections are similar, and careful planning is required.
• "Indications for and Timing of Initiation of KRT." (2023) — PMID 36100262 — Indications for starting replacement therapy in acute kidney injury have been debated for decades, considering patient preferences and treatment goals together.
• "New Paradigms in Nephrology Nursing." (2025) — PMID 40308407 — Conservative care is comprehensive treatment without dialysis for preserving residual function, relieving symptoms and complications, and individual palliative care for the physical, emotional, and spiritual well-being of patients and families.
• "Frailty in patients on dialysis." (2024) — PMID 38705274 — Frailty involves weight loss, exhaustion, low activity, weakness, and slow gait, is common in dialysis patients, and increases the risk of decreased quality of life, hospitalization, infection, and death, with no cure.
• "Conservative kidney management versus dialysis for stage 5 chronic kidney disease in older people." (2025) — PMID 41363177 — 24 non-randomized studies with 26,127 participants aged 65 and older (23 studies with 24,628 participants in mortality analysis), no RCTs, mortality 813 (conservative) vs 630 (dialysis) per 1,000, unstated duration relative risk 1.28 with very low certainty, imbalance in prognostic factors, and uncertain effects on mortality, hospitalization, and quality of life.