Conservative kidney management versus dialysis for stage 5 chronic kidney disease in older people.

RATIONALE: The prevalence of kidney failure in people aged 65 years and above is gradually increasing. However, there is insufficient evidence to determine which treatment is better for people with kidney failure, conservative kidney management (CKM) or dialysis. OBJECTIVES: We aimed to assess the effects of CKM and dialysis in older people with kidney failure. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies, MEDLINE, Embase, the WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and regional databases (LILACS, KoreaMed, CADTH), as well as grey literature repositories up to 22 September 2025. ELIGIBILITY CRITERIA: Randomised and non-randomised studies evaluated CKM compared to dialysis in people aged 65 years and above with kidney failure. OUTCOMES: The critical outcomes included death (any cause), cardiovascular death, cardiovascular events, and health-related quality of life (HRQoL). The important outcomes included overall adverse events, hospitalisation, malnutrition, sarcopenia, and residual kidney function. RISK OF BIAS: Two authors independently performed the risk of bias analysis. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. SYNTHESIS METHODS: Treatment estimates were summarised using random effects pair-wise meta-analysis and expressed as a relative risk (RR), mean difference (MD), or standard mean difference (SMD) with a corresponding 95% confidence interval (CI). Evidence certainty was assessed using GRADE. INCLUDED STUDIES: We included 24 non-randomised studies that involved 26,127 people with kidney failure. These studies compared CKM to dialysis. SYNTHESIS OF RESULTS: Compared to dialysis, CKM had uncertain effects on death (any cause) (23 studies, 24,628 participants: 813 per 1000 with CKM versus 630 per 1000 with dialysis) (RR 1.28, 95% CI 1.17 to 1.41; I² = 89%; very low-certainty evidence) and cardiovascular death (3 studies, 262 participants: 114 per 1000 with CKM versus 66 per 1000 with dialysis) (RR 1.72, 95% CI 0.68 to 4.34; I² = 0%; very low-certainty evidence). For HRQoL, the Physical Component Summary (PCS) score (2 studies, 186 participants) was on average about 1.46 points lower with CKM compared with dialysis (MD -1.46, 95% CI -12.08 to 9.16; I² = 77%; very low-certainty evidence). The Mental Component Summary (MCS) score (2 studies, 186 participants) was about 2.5 points lower with CKM (MD -2.50, 95% CI -7.82 to 2.82; I² = 19%; very low-certainty evidence). We found no randomised controlled trials. The certainty of evidence from non-randomised studies was very low due to a high risk of bias, because of significant imbalances in prognostic factors that could not be fully addressed. None of the included studies reported cardiovascular events, malnutrition, sarcopenia, residual kidney function, or adverse events. AUTHORS' CONCLUSIONS: CKM had uncertain effects on death (any cause), cardiovascular death, hospitalisation, and HRQoL compared to dialysis. FUNDING: Supported by the National Evidence‑based Healthcare Collaborating Agency (NA21‑001). REGISTRATION: Protocol available via https://doi.org/10.1002/14651858.CD015151.