Optimal patient care in advanced chronic kidney disease progressing to kidney failure

The transition from advanced chronic kidney disease (CKD) to kidney failure requires comprehensive management to optimize patient outcomes. This crucial period, in practical terms defined by CKD stages G4 and G5, involves complex decision-making regarding kidney replacement therapy, pre-emptive kidney transplantation and conservative kidney management. Patient preferences, quality of life, and comorbidities, especially cardiovascular disease, are essential considerations when making treatment decisions. Importantly, nephroprotective therapies should be continued even at advanced stages of CKD to stabilize kidney function and prevent cardiovascular events. Pre-emptive kidney transplantation, when feasible, offers the best outcomes and should be prioritized. Dialysis initiation should be based on clinical symptoms and shared decision-making with the patient, rather than laboratory values alone. For some, particularly older, patients with substantial comorbidities, conservative kidney management, emphasizing symptom management without kidney replacement therapy, might be preferred. Considerable disparities in access to care exist globally, especially in low- and middle-income countries, highlighting the need for tailored strategies. Registry and cohort studies have provided most of the scientific understanding in this area, but more randomized clinical trials are needed to guide advanced CKD management.