Conservative Care Management in Chronic Kidney Disease: A Value for the Money?


  • Ana Farinha Coordinator of the Working Group of Conservative Care in CKD from Sociedade Portuguesa de Nefrologia; Nephrology Department, Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal Author
  • Pedro Barata Coelho Faculdade de Ciências da Saúde da Universidade Fernando Pessoa, Centro Académico Clínico do ICBAS‐CHUP, I3S‐Universidade do Porto, Porto, Portugal Author
  • António Teixeira Rodrigues Centre for Health Evaluation & Research/ Infosaúde, National Association of Pharmacies (CEFAR/ ANF), Lisbon, Portugal; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3Bs PT Government Associate Laboratory, Braga/Guimarães, Portugal Author


Cost of Illness, Health Care Costs, Kidney Failure, Chronic/economics, Renal Insufficiency, Chronic/economics


End stage kidney disease (ESKD) is a potentially fatal disease that can be treated by one of three modalities: dialysis (hemodialysis or peritoneal dialysis) and kidney transplantation. Either of these options represents a heavy burden on health systems. Kidney transplantation has its own financial framework. Dialysis care, provided by public or private institutions is funded, since 2008, by a prospective bundle payment system called preço compreensivo (“comprehensive price”). In 2011, Direção Geral de Saúde (Directorate General of Health) proposed in “Norma 17” a fourth modality to handle ESKD: conservative care management (or kidney palliative care). This option focuses treatments on improving quality of life (and in some cases, time) in frail patients or patients who opt not to proceed to invasive treatment op‐ tions. “Norma 17” regulated the clinical framework for this proposal but its socioeconomic evaluation and subsequent reimbursement has not been established. This has become a barrier to its application by public and private providers. This work intends to reflect the individual, social and economic benefits of the implementation of the conservative care option so healthcare decision makers may support their decisions. The authors reflect on the limitations to analyze costs and results in end‐of‐life care and propose outcomes to compare dialysis and conservative care in ESKD.


Download data is not yet available.


Portal do INE [Internet]. [cited 2023 May 22]. Available from: https://‐ corrCod=0011651&contexto=bd&selTab=tab2

Brück K, Stel VS, Gambaro G, Hallan S, Völzke H, Ärnlöv J, et al. CKD Prevalence Varies across the European General Population. J Am Soc Nephrol. 2016;27:2135–47.

Sociedade Portuguesa de Nefrologia. Gabinete do Registo da Doença Renal Crónica da Sociedade Portuguesa de Nefrologia. Lisboa: SPN; 2020.

ERA Registry Annual Report 2020 REGISTRY.

Portugal. Lei constitucional n.o 1/2005, de 12 de Agosto [Internet]. [cited 2023 May 28]. Available from:

Bikbov B, Purcell CA, Levey AS, Smith M, Abdoli A, Abebe M, et al. Global, regional, and national burden of chronic kidney disease, 1990‐2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2020;395:709–33. doi: 10.1016/ S0140‐6736(20)30045‐3.

MARCOS HISTÓRICOS DA DIÁLISE ‐ Anadial [Internet]. [cited 2023 May 28]. Available from: marcos‐historicos‐da‐dialise/

Muñoz‐Terol JM, Rocha JL, Castro‐de la Nuez P, García‐Cabrera E, Vilches‐Arenas Á. Years of potential life lost on renal replacement therapy: retrospective study cohort. J Clin Med. 2022;12:51. doi:10.3390/jcm12010051.

Saini T, Murtagh FE, Dupont PJ, McKinnon PM, Hatfield P, Saunders Y. Comparative pilot study of symptoms and quality of life in cancer patients and patients with end stage renal disease. Palliat Med. 2006;20:631–6. doi: 10.1177/0269216306070236.

Murtagh FEM, Burns A, Moranne O, Morton RL, Naicker S. Supportive Care: Comprehensive Conservative Care in End‐Stage Kidney Disease. Clin J Am Soc Nephrol. 2016;11:1909‐14. doi: 10.2215/ CJN.04840516.

Murtagh FEM, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant. 2007;22:1955–62.

Carson RC, Juszczak M, Davenport A, Burns A. Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol. 2009;4:1611–9.

Joly D, Anglicheau D, Alberti C, Nguyen AT, Touam M, Grünfeld JP, et al. Octogenarians Reaching End‐Stage Renal Disease. J Am Soc Nephrol. 2003;14:1012‐21. doi: 10.1097/01.asn.0000054493.04151.80.

Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361:1539‐47. doi: 10.1056/NEJMoa0904655.

Wong SPY, Kreuter W, O’Hare AM. Healthcare intensity at initiation of chronic dialysis among older adults. J Am Soc Nephrol. 2014;25:143‐‐9. doi: 10.1681/ASN.2013050491.

Chandna SM, Da Silva‐Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26:1608‐14. doi: 10.1093/ndt/gfq630.

Arnold RM, Zeidel ML. Dialysis in frail eldersa role for palliative care. N Engl J Med [Internet]. 2009;361:1597–8.

O’Connor NR, Kumar P. Conservative management of end‐stage renal disease without dialysis: a systematic review. J Palliat Med. 2012;15:228‐35. doi: 10.1089/jpm.2011.0207.

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. [cited 2023 May 22]; Available from:

Jassal SV, Chiu E, Hladunewich M. Loss of independence in patients starting dialysis at 80 years of age or older. N Engl J Med. 2009;361:1612–3.

Shah KK, Murtagh FEM, McGeechan K, Crail S, Burns A, Tran AD, et al. Health‐related quality of life and well‐being in people over 75 years of age with end‐stage kidney disease managed with dial‐ ysis or comprehensive conservative care: a cross‐sectional study in the UK and Australia. BMJ Open. 2019;9:e027776. doi: 10.1136/ bmjopen‐2018‐027776.

Davison SN, Jassal SV. Supportive Care: Integration of Patient‐Centered Kidney Care to Manage Symptoms and Geriatric Syndromes. Clin J Am Soc Nephrol. 2016;11:1882‐91. doi: 10.2215/ CJN.01050116.

Harris DCH, Davies SJ, Finkelstein FO, Jha V, Donner JA, Abraham G, et al. Increasing access to integrated ESKD care as part of uni‐ versal health coverage. Kidney Int. 2019;95:S1‐S33. doi: 10.1016/j. kint.2018.12.005.

Wong SPY, Kreuter W, O’Hare AM. Treatment intensity at the end of life in older adults receiving long‐term dialysis. Arch Intern Med. 2012;172:661‐3; discussion 663‐4. doi: 10.1001/ archinternmed.2012.268.

Richards CA, Liu CF, Hebert PL, Ersek M, Wachterman MW, Reinke LF, et al. Family Perceptions of Quality of End‐of‐Life Care for Veterans with Advanced CKD. Clin J Am Soc Nephrol. 2019;14:1324‐35. doi: 10.2215/CJN.01560219.

Moss AH. Improving end‐of‐life care for dialysis patients. Am J Kidney Dis. 2005;45:209‐12. doi: 10.1053/j.ajkd.2004.10.010. P

Davison SN. End‐of‐life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5:195–204.

Teno JM, Gozalo PL, Bynum JPW, Leland NE, Miller SC, Morden NE, et al. Change in end‐of‐life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309:470–7. doi: 10.1001/jama.2012.207624.

Feely MA, Swetz KM, Zavaleta K, Thorsteinsdottir B, Albright RC, Williams AW. Reengineering Dialysis: The Role of Palliative Medicine. J Palliat Med. 2016;19:652–5.

Norma 17 [Internet]. [cited 2023 May 22]. Available from: https://‐da‐dgs/normas‐e‐circulares‐normativas/ norma‐n‐0172011‐de‐28092011‐atualizada‐a‐14062012‐jpg.aspx

Grubbs V, Tuot DS, Powe NR, O’Donoghue D, Chesla CA. System‐Level Barriers and Facilitators for Foregoing or Withdrawing Dialysis: A Qualitative Study of Nephrologists in the United States and England. Am J Kidney Dis. 2017;70:602–10. doi: 10.1053/j.ajkd.2016.12.015.

Thorsteinsdottir B, Swetz KM, Tilburt JC. Dialysis in the frail elderly ‐ a current ethical problem, an impending ethical crisis. J Gen Intern Med. 2013;28:1511‐6. doi: 10.1007/s11606‐013‐2494‐1.

Verberne WR, Tom Geers AB, Jellema WT, Vincent HH, van Delden JJ, Bos WJ. Comparative survival among older adults with advanced kidney disease managed conservatively versus with dialysis. Clin J Am Soc Nephrol. 2016;11:633‐40. doi: 10.2215/CJN.07510715.

Harris DCH, Davies SJ, Finkelstein FO, Jha V, Bello AK, Brown M, et al. Strategic plan for integrated care of patients with kidney failure. Kidney Int. 2020;98:S117–34. doi: 10.1016/j.kint.2020.07.023.

Davison SN, Levin A, Moss AH, Jha V, Brown EA, Brennan F, et al. Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care. Kidney Int. 2015;88:447–59. doi: 10.1038/ki.2015.110.

Kurella Tamura M, O’Hare AM, Lin E, Holdsworth LM, Malcolm E, Moss AH. Palliative Care Disincentives in CKD: Changing Policy to Improve CKD Care. Am J Kidney Dis. 2018;71:866–73. doi: 10.1053/j. ajkd.2017.12.017.

Bajwah S, Oluyase AO, Yi D, Gao W, Evans CJ, Grande G, et al. The effectiveness and cost‐effectiveness of hospital‐based specialist palliative care for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2020;9:CD012780. doi: 10.1002/14651858. CD012780.pub2.

Hain D, Paiva LM, Poole B. Preparing For the future: Advanced care planning for the patient with ESRD. Nephrol News Issues. 2015;2:16‐8.

Lam DY, Scherer JS, Brown M, Grubbs V, Schell JO. A Conceptual Framework of Palliative Care across the Continuum of Advanced Kidney Disease. Clin J Am Soc Nephrol. 2019;14:635‐41. doi: 10.2215/ CJN.09330818

Lupu DE, Murphy E. Models for Operationalizing Supportive Care in Kidney Care. Palliative Care in Nephrology [Internet]. 2020 Aug [cited 2023 May 28];36–46. Available from: book/29498/chapter/265520254

Farinha A, Valério P, Borges L, Lourenço A. Supportive Care Program in CKD: from dream to reality. Port J Nephrol Hypert. 2021;35:219– 23. doi: 10.32932/pjnh.2021.12.153

May P, Cassel JB. Economic outcomes in palliative and end‐of‐life care: Current state of affairs. Ann Cardiothorac Surg. 2018;7:S244–8. 43. Marik PE. The cost of inappropriate care at the end of life. Am J Hosp Palliat Care. 2015;32:703‐8. doi: 10.1177/1049909114537399.

Zahirian Moghadam T, Powell J, Sharghi A, Zandian H. Economic evaluation of dialysis and comprehensive conservative care for chronic kidney disease using the ICECAP‐O and EQ‐5D‐5L; a comparison of evaluation instruments. Cost Eff Resour Alloc. 2023;21:81.






Review Article

How to Cite

Conservative Care Management in Chronic Kidney Disease: A Value for the Money?. (2024). Portuguese Kidney Journal, 38(1), 35-42.

Most read articles by the same author(s)

Similar Articles

1-10 of 18

You may also start an advanced similarity search for this article.