Conservative Management in Chronic Kidney Disease: A Concept Analysis

Conservative Management in Chronic Kidney Disease: A Concept Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Conservative Management in Chronic Kidney Disease: A Concept Analysis Chisomo Mulenga, Catherine Titanus Mselema, Felistas Chiundira, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9289097/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Conservative management for patients with Chronic Kidney Disease (CKD) is recognized as a viable alternative for patients who are unsuitable for, unable to access, or choose not to undergo dialysis. However, this concept is not well-defined, which affects its application. This study aims to clarify the concept of conservative management in the context of CKD. Methods: A concept analysis was conducted using Walker and Avant’s framework. Literature search was conducted across various databass. After screening, nineteen articles met the inclusion criteria and were included in the analysis. Data were analysed to identify attributes, antecedents, consequences, and empirical referents of conservative management. Results: Antecedents were identified at the patient, provider, and health system levels. The consequences include improved quality of life for patients and caregivers, reduced hospital utilisation and healthcare costs, and enhanced patient control over illness, despite a comparatively limited survival benefit. Conclusion: Conservative management is a key alternative care pathway for individuals with advanced CKD. It could lead to improved quality of life, reduced treatment burden, and enhanced patient autonomy, although survival benefits appear to be limited Nursing Chronic Kidney Disease End-Stage Kidney Disease CKD ESKD Conservative Management Conservative Care Conservative Kidney Management Figures Figure 1 Figure 2 Introduction Chronic Kidney Disease (CKD) is a significant contributor to the global disease burden and is rapidly becoming a major public health concern (Mohamed Hussin & Syed Jamaludin, 2024 ). Current estimates indicate that approximately 850 million people worldwide suffer from CKD (Bello et al., 2023 ). The prevalence of CKD globally is approximately double that of diabetes (422 million) and 20 times that of cancer (42 million) and HIV/AIDS (36.7 million) (Jager et al., 2019 ). CKD progresses through five stages based on the estimated glomerular filtration rate (eGFR) (Lunney et al., 2020 ). Earlier stages (1, 2, and 3) may not present any symptoms and can potentially be reversed with medical intervention (Subramonian & Frey, 2020 ). CKD stage 4 indicates severe kidney function loss, whereas stage 5 CKD, also called End Stage Kidney Disease (ESKD), is an advanced stage of CKD where there is irreversible loss of kidney function (George et al., 2017 ). Notably, the majority of CKD patients (79%) receive their diagnosis during the advanced stages 3–5, indicating a delayed recognition of the condition and requiring effective medical management (López et al., 2023 ). Renal replacement therapy (RRT), which includes dialysis and kidney transplantation, is the primary treatment for patients with CKD in the final stages of the disease (Lunney et al., 2020 ). However, RRT is associated with a substantial financial burden, limiting access for many patients in low-resource settings (Ashuntantang et al., 2017 ; Ng & Li, 2018 ). Data from the International Society of Nephrology Global Kidney Health Atlas for Africa (2018) indicate that the annual costs of haemodialysis (HD) and peritoneal dialysis (PD) are prohibitively high, with median annual costs per patient ranging from US $ 5,980 to US $ 22,731 for HD and US $ 6,895 to US $ 34,165 for PD (Okpechi et al., 2024 ). Correspondingly, the proportion of patients with stage 5 CKD who are not receiving treatment, including HD, PD, or transplantation, is much higher in Low-Income Countries (LICs) (98%) and LMICs (94%) than in Upper-Middle-Income Countries (UMICs) (79%) and High-Income Countries (HICs) (30%) (Bello et al., 2023 ). On the other hand, RRT may not be suitable for certain populations, such as the elderly and those with multiple comorbidities (Davison et al., 2019 ; Zarantonello et al., 2021b ). Therefore, many countries are increasingly offering conservative management option (Zarantonello et al., 2021b ). Although widely recognised and utilised, conservative management remains a relatively new treatment modality that lacks clear definition (Davison et al., 2015b ). Despite its popularity, several unknowns remain regarding its optimal adoption in practice and delivery (Murtagh et al., 2016 ). The absence of common terminology associated with this approach further compounds the problem, making it difficult to identify the healthcare needs of patients and systematically study ways to enhance care and outcomes (Gelfand, 2023 ; Sakthivel et al., 2024 ). Currently, there is no uniformity in the implementation of this option in daily practice (Chotivatanapong et al., 2024 ; Susanto et al., 2018 ). This concept analysis, therefore, aimed to elucidate the concept of conservative management in the context of CKD by expounding on its defining characteristics, antecedents, and consequences. Furthermore, this analysis presents model, borderline, and contrary cases, and empirical referents to provide a more comprehensive understanding of the concept. This analysis may facilitate the effective implementation of conservative management strategies for CKD. Materials and Methods Design This study employed Walker and Avant’s concept analysis approach. This method involves eight steps: selecting the concept; determining the aims or purpose of the analysis; identifying all uses of the concept; determining the defining attributes; constructing a model case; identifying borderline, related, contrary, invented, and illegitimate cases; identifying antecedents and consequences; and empirical referents (Walker & Avant, 2019 ). After selecting the concept and establishing the aim of the analysis, an integrative literature review was conducted to identify the uses of conservative management in the literature and determine its defining attributes, antecedents, and consequences. A model case and other cases were then developed based on the identified attributes, and empirical referents were identified to clarify how the concept could be measured or observed in practice. Search Strategy A comprehensive literature search was conducted using the PubMed, Embase, Scopus, Web of Science, and Google Scholar electronic databases. Manual searches of the reference lists of the relevant articles were also performed to identify additional eligible studies. The search strategy was guided by the Population, Concept, and Context (PCC) framework, as recommended by the Joanna Briggs Institute (Peters et al., 2020 ); (Table 1 ). Boolean operators (AND, OR) were used to combine keywords to ensure the comprehensive retrieval of relevant literature. Table 1 PCC Framework PCC Element Description / Key Concepts Related Terms Population (P) Adults diagnosed with Chronic Kidney Disease (CKD), especially those in stages 3–5, including those not eligible for, unable to access or choosing not to undergo dialysis or kidney transplantation. Chronic Renal Failure (CRF), Chronic Kidney Disease (CKD), End-Stage Kidney Disease (ESKD / ESRD), Chronic Renal Insufficiency, Chronic Kidney Insufficiency, Advanced Kidney Disease, Non-dialysis CKD patients, Elderly CKD patients, Patients declining dialysis Concept (C) Conservative Management : A patient-centred, non-dialytic approach to care that focuses on symptom control, psychosocial and spiritual support, and advanced care planning. Non-dialytic management, Conservative kidney management, Conservative care pathway, Non-renal replacement therapy, Palliative renal care, Supportive kidney care, Integrated palliative nephrology, Symptom management in CKD, Kidney supportive care Context (C) Settings and circumstances where conservative management is provided within healthcare systems, palliative care programs, or community-based environments, especially in resource-limited settings. Primary care settings, Nephrology clinics, Hospice and palliative care units, Community-based care, End-of-life care settings, Outpatient management, Home-based renal care Inclusion and Exclusion Criteria Articles were included if they focused on conservative management, were published in English between 2015 and 2025, and had their full texts available. Studies were excluded if they were published before 2015, lacked clearly stated aims or methodology, were inaccessible in full text, or contained incomplete data, such as protocols for systematic or scoping reviews. Study Selection All retrieved records were imported into the Rayyan app (Ouzzani et al., 2016 ) for duplicate removal and screening. After the duplicate records were removed, the remaining articles were screened against the inclusion criteria based on their titles and abstracts, and the full texts of potentially eligible articles were retrieved for detailed assessment. The initial search yielded 213 articles, of which 157 remained after the duplicates were removed. A total of 84 articles were excluded after screening the titles and abstracts. A full-text review of the remaining 73 articles led to the exclusion of 54 articles that did not meet the eligibility criteria. The final analysis included 19 studies (Fig. 1 ) and Appendix 1. Charting Data and Collating Results A data extraction sheet (Appendix 1) was developed to systematically chart the relevant details from the eligible studies. The sheet captured information including author, year, and country, study aim, key results (attributes, antecedents, consequences, and empirical referents), and the term(s) used for the concept. The extracted data were then collated, compared, and synthesised to identify common patterns and variations across studies, facilitating the delineation of the defining attributes, antecedents, consequences, and empirical referents of conservative management in CKD. Results Identifying all Uses of the Concept Conservative management is a term that combines two distinct concepts: "conservative" and "management.” According to the Merriam-Webster Dictionary (Merriam-Webster, 2024 ), conservative means not extreme or drastic, and is intended to preserve or restore function. In contrast, management refers to an approach to healthcare delivery that focuses on the complex needs of patients and prioritises the coordination of all necessary services (Farlex Partner Medical Dictionary, 2012 ). Therefore, conservative management is an approach to patient care that involves avoiding intrusive measures, such as surgery or other invasive procedures, usually with the intent to preserve function or body parts (kellybrendel, 2021). In relation to CKD, Lunney et al. ( 2021 ) defined conservative management as an alternative therapy for kidney failure that prioritises symptom management, psychological health, spiritual care, and support from family and society. In this case, the use of an alternative implies that it is a substitute for RRT. Combs and Davison (Combs & Davison, 2015 ) defined conservative management as a comprehensive plan that combines palliative care principles with interventions to slow CKD progression and reduce complications without the need for dialysis. The plan includes several elements, such as advance care planning (ACP), completing advance directives or physician orders for life-sustaining treatments, aggressive symptom management, emotional support for both patients and their families, shared decision-making, and involvement of a multidisciplinary team (Combs & Davison, 2015 ). To address misconceptions about conservative management, the Kidney Disease: Improving Global Outcomes (KDIGO) conference recommended the use of the term comprehensive conservative care (Davison et al., 2015b ). They further defined the concept as a holistic, patient-centred approach that includes interventions to delay the progression of kidney disease, minimise the risk of complications, and involve shared decision-making, active symptom management, detailed communication (including advance care planning), psychological support, social and family support, and cultural and spiritual support without dialysis (Davison et al., 2015b ). Similarly, Subramonian and Frey (Subramonian & Frey, 2020 ) defined conservative management by focusing on the clinical effectiveness of this approach. They defined conservative management as an approach that involves comprehensive non-dialysis care that aims to prolong kidney function, manage symptoms associated with acidosis, anaemia, bone and mineral metabolism, and blood pressure, and provide dietary support. This approach also involves individualising care by offering shared decision-making and psychological, social, and spiritual support to the patients. Murakami et al. ( 2023 ) defined conservative management as active medical management of advanced CKD without dialysis, focusing on delaying the worsening of kidney disease and minimising the symptom burden. Davison et al. (Davison et al., 2019 ) in a study aimed at making recommendations on the care of patients on conservative management, identified the crucial components of conservative kidney management. These include: effective communication, shared decision-making, advance care planning, and psychosocial support. The recommendations also underscore the significance of preserving physical, cognitive, and kidney functions while simultaneously addressing the symptoms. Sakthivel et al. ( 2024 ) discussed conservative management in terms of the aim, which is to manage symptoms and delay disease progression without dialysis; and management, which involves active medical and lifestyle interventions, such as medications, and dietary modifications. Surrogate Terms Various alternative terms have been used to describe conservative management for CKD. For example, in the United Kingdom (UK), common alternative terms include maximum conservative management, conservative kidney care, and palliative kidney care (Okamoto et al., 2015 ). The Renal Physicians Association Shared Decision-Making Guideline refers to it as "active medical management without dialysis," while the KDIGO recommends the term "comprehensive conservative care (Davison et al., 2015b )." Other terms such as renal supportive care, supportive care, and end-of-life care have also been used interchangeably with conservative management (Murtagh et al., 2016 ). While the other aforementioned names mean the same thing as conservative management, the use of terms like "supportive care" end-of-life care, and "palliative care" synonymously with conservative management is problematic and confusing, according to Murtagh et al. ( 2016 ). Kidney supportive care refers to services intended to improve the quality of life of patients of any age with established CKD. These services can be provided alongside treatments that aim to prolong life, such as dialysis (Davison et al., 2015b ). Although end-of-life care shares the same philosophy, it is typically limited to patients who are believed to be within months of death and fall under the larger umbrella of supportive care (Prabhu et al., 2021 ). Palliative care is an approach that aims to improve the quality of life of patients, including adults and children, and their families, who are experiencing problems associated with life-threatening illnesses. It involves the early identification, correct assessment, and treatment of pain and other physical, psychosocial, and spiritual problems to prevent and relieve suffering (World Health Organization, 2020 ). Palliative care can be provided together with therapies intended to prolong life, including dialysis, and focuses on the relief of suffering, whether the patient is on dialysis or not (Belino et al., 2018 ). Kidney supportive care, end-of-life care, and palliative care are umbrella terms encompassing all aspects of management, including conservative management and RRT. Therefore, conservative management should not be used synonymously, as it specifically focuses on non-dialysis treatment. Operational Definition of Conservative Management Conservative management is comprehensive and individualised non-dialysis patient care that involves a multidisciplinary approach, shared decision-making, advance care planning, proactive symptom identification and management, and patient and family support to enhance patients’ health-related quality of life. Defining Attributes of Conservative Management in Chronic Kidney Disease Literature review led to the identification of nine attributes, as shown in Fig. 2 . The attributes include: holistic approach to care, patient-centred care, advance care planning, shared decision-making, multidisciplinary care, proactive symptom recognition and management, preservation of functional status (cognitive, physical, and kidney), non-dialytic management, and sustained patient and family support (psychological, social, spiritual, and cultural). Holistic Approach to Care Holistic care is complete or total patient care that considers the physical, emotional, social, economic, and spiritual needs of the person, their response to the illness, and the effect of the illness on their ability to meet self-care needs (Ventegodt et al., 2016 ). Chronic kidney disease and its treatment affect all dimensions of a patient’s life and consequently their QoL (Yapa et al., 2023 ). Therefore, a holistic approach to care would ensure that patients experience a high QoL. Patient-Centered Care Patient-centred care respects and responds to individual patient preferences, needs, and values, ensuring that patient values guide all clinical decisions (Freidin et al., 2019 ). A patient-centred approach is preferable over a disease-based approach when managing CKD because patients with CKD often suffer from multiple chronic conditions, which may require different and sometimes conflicting treatments and targets. Moreover, each patient may have different priorities and values regarding treatment outcomes. Therefore, the potential benefits and risks of a particular treatment can vary significantly among patients (Eilers, 2018 ; Freidin et al., 2019 ). Under a patient-centred approach, medical evidence and knowledge are evaluated in the unique context of the person being cared for and applied judiciously to uphold what is important to them (Freidin et al., 2019 ). Advance Care Planning Advanced care planning is a communication process that leads to decisions about the goals of future care and requires provider input on prognosis, options for care, and assurance of ongoing management, regardless of the choices made (Raghavan & Holley, 2016 ). The unpredictable illness trajectories of CKD and progressive cognitive decline highlight the importance of early ACP with ongoing communication and re-evaluation throughout the illness to ensure that end-of-life crises are avoided and that care remains consistent with patients’ wishes (Holley, 2012 ). ACP allows for smooth transitions between illness progression, choice of treatment, and wishes for family and everyday life (Frandsen et al., 2023 ). Some issues addressed in advance care planning include the choice of treatment options and end-of-life preferences, such as the place of death (Moss et al., 2020 ). Shared Decision Making Shared decision-making is a patient-centred approach in which choices are viewed within the explicitly discussed values and preferences of the patient (Davis & Davison, 2017 ). In shared decision-making, decisions about RRT modalities or conservative management are made jointly with the patient, their family members, and the healthcare team, considering the predicted quality of life, predicted life expectancy, the patient’s preferences, and other factors, such as co-existing conditions (National Institute for Health and Care, 2018 ). The goal of shared decision-making is to align treatment with patient and family goals, values, preferences, and medical concerns (Davison et al., 2015a ; Subramonian & Frey, 2020 ) Specifically, designed patient decision aids / tools are used to facilitate discussion (Davis & Davison, 2017 ). Multidisciplinary Care Considering the diverse needs of patients with CKD and the complexity of the condition, a multidisciplinary approach is required to provide comprehensive and continuous care (Hsu et al., 2021 ). The multidisciplinary team may comprise the following: nephrologists, general practitioners, nurses, psychosocial workers, counselors or psychologists, dieticians, pharmacists, allied health professionals, chaplains, family doctors, community staff/health-care volunteers depending on the country and region (Davison et al., 2015b ; Hsu et al., 2021 ; Palat et al., 2021 ). Each of these team members has distinct roles; for instance, the nephrologist is responsible for medical management, nurses focus on providing CKD-related health education and guiding lifestyle changes, dieticians provide dietary counselling, and psychologists focus on mental health issues affecting the patient and caregivers (Hsu et al., 2021 ). Additional training or expertise in comprehensive conservative care is recommended for all healthcare workers involved in renal medicine (Palat et al., 2021 ). Proactive Symptom Recognition and Management Patients with CKD stage 5 have a high symptom burden caused by factors related to the disease process (metabolic derangements) and comorbidities (Davison et al., 2015b ; Moss et al., 2020 ; Murtagh et al., 2016 ). According to Murtagh et al. (Murtagh et al., 2016 ) the number of symptoms may range from 6.8 to 17 per patient. Therefore, proactive symptom recognition and management are integral aspects of conservative management (Moss et al., 2020 ; Raghavan & Holley, 2016 ). Both non-pharmacological and pharmacological strategies are used to manage the symptoms (Davison et al., 2015b ). Preservation of Functional Status (cognitive, physical, and kidney) The goals of CKD managementare to slow disease progression and preserve kidney function, which ultimately promotes the HRQoL (Kalantar-Zadeh et al., 2021 ). Health-related quality of life has four dimensions: physical, psychological, emotional, and social (Song, 2016 ). Therefore, the preservation of function applies to all the dimensions. Non-dialytic Management Conservative management is sometimes referred to as active medical management without dialysis, as it focuses only on pharmacological and non-pharmacological interventions (Moss et al., 2020 ). This attribute is a key feature in differentiating conservative management from other terms, such as supportive care, end-of-life care, and palliative care, which are sometimes erroneously used interchangeably with conservative management (Belino et al., 2018 ; Davison et al., 2015b ). Sustained Patient and Family support Patients with CKD are exposed to multiple physical and psychosocial stressors due to the illness (Yapa et al., 2023 ). The biopsychosocial impact of CKD has been proposed to account for poorer QoL compared to that of patients with other chronic diseases (Bale et al., 2016 ). Furthermore, survey data have shown a significant correlation between poor QoL and higher morbidity and mortality in patients with ESKD (Song, 2016 ). Thus, Patients with CKD and their families need sustained support in all domains of life. Increased social support has the potential to positively affect outcomes through several mechanisms, including decreased levels of depressive effects, increased patient perception of QoL, increased access to healthcare, increased patient compliance with prescribed therapies, and direct physiological effects on the immune system (Bale et al., 2016 ). Model Case Walker and Avant (Walker & Avant, 2019 ) define a model case as an example that demonstrates all the defining attributes of a concept. This is a case of Mr. X, a 75-year-old man, who presented to the hospital with complaints of fatigue, loss of appetite, vomiting, reduced urine output, leg swelling and shortness of breath. The patient had a history of hypertension and type 1 diabetes mellitus. The blood pressure was 170/100 mmHg, the random blood sugar level was 450 mg/dl, and the haemoglobin level was 8 g/dl. His eGFR was 10 mL/min/1.73m², and ESKD was diagnosed. He was prescribed medication to manage his blood pressure, anaemia, fluid overload, and vomiting, and to control his blood sugar level. He was educated on lifestyle changes. A team of healthcare professionals, including a nephrologist, nurse, dietician, psychologist, and clergy, was involved in Mr. X's care. The patient’s family was included in the care plan. Mr. X’s nephrologist and nurse discussed the treatment options available for ESKD with him and his family. The team considered various factors, such as Mr. X's age, pre-existing health conditions, predicted quality of life, life expectancy, and personal preferences. Decision aids were used to assist the team in making the appropriate choices. Considering these factors, the team agreed that conservative management would be the best course of action for Mr. X, who was advised to indicate his future treatment preferences. Mr. X and his family were also referred to renal support groups in their communities. Mr. X was regularly followed up at the clinic, where the assessment findings indicated that his overall HRQoL had improved. Analysis This case exemplifies the effective implementation of conservative management strategies. Mr. X’s care encompassed all aspects of his life, including the physical, psychological, social, and spiritual dimensions, exhibiting a holistic approach. The management plan was tailored to Mr. X's specific symptoms, characteristics, and preferences, reflecting a patient-centred approach with active symptom recognition and management. The decision-making process is shared among Mr. X, his family, the nephrologist, and the nurse, with advance care planning in place. A multidisciplinary team was involved in the management of Mr. X. Non-dialysis treatment was chosen to manage the patient’s symptoms and preserve function. Support was provided to Mr. X and his family, including necessary information and referrals to support groups. The ultimate goal of this approach was to enhance Mr. X's QoL and optimise his overall well-being, which was evident during follow-up care. Borderline Case A borderline case contains most of the defining attributes of the concept being examined, but not all of them (Walker & Avant, 2019 ). Mr P, 45 years old, presented to the hospital with complaints of shortness of breath, fatigue, reduced urine output, generalised oedema, nausea, and reduced appetite. The patient had a history of heart failure. On assessment, the pulse rate was 110 beats per minute, the respiration rate was 28 breaths per minute, blood pressure was 160/90 mmHg, and oxygen saturation was 96%. His haemoglobin level was 8.5 g/dl, and the eGFR was 13 mL/min/1.73m²; therefore ESKD was diagnosed. He was prescribed medications to manage his blood pressure, anaemia, fluid overload, and loss of appetite. Mr P was managed by physicians, nurses, dieticians, and social workers. The patient’s family was also included in the care plan. Mr. P's physician informed him and his family about conservative management as a treatment plan. Mr. P and his family were referred to renal support groups within their community to ensure that they receive the necessary support. Analysis This case fits well within the context of borderline cases. Mr. P received individualised care based on his presenting complaints from a multidisciplinary team available in the setting. He was placed on non-dialysis management and received support from his family. However, shared decision-making and advance care planning, which are important attributes of conservative management, were not implemented. Contrary Case A contrary case does not reflect the concept (Walker & Avant, 2019 ). Mrs. B, aged 76 years, presented to the hospital with complaints of general body weakness, reduced urine output, oedema of the lower extremities, pruritus, loss of appetite, and poor general health for the past 6 months. Mrs. B was HIV-positive and had been receiving antiretroviral therapy for 30 years. She also had a history of hypertension, heart failure, and type 1 diabetes mellitus. Upon assessment, her blood pressure was 180/ 100 mmHg, CD4 count was 400 cells/mm^3, random blood sugar was 400 mg/dl, heamoglobin was 7 g/dl, and her estimated glomerular filtration rate was 8 mol/min/173. Mrs B. was diagnosed with ESKD. Mrs. B was told to continue taking her current medication. The admitting doctor, who is a general practitioner, informed Mrs. B and her husband, who accompanied her to the hospital about her diagnosis and the need to initiate hemodialysis. No explanations were provided regarding the available options or the advantages and disadvantages of each option. Multidisciplinary team members were not involved in the care, apart from the nurses in the ward, who were just told what to do. Mrs. B was initiated on dialysis three times a week, but after having a few sessions, she failed to cope with the treatment as she developed other dialysis-related symptoms. Mrs. B and her husband decided to stop dialysis and spend the remaining days at home with family. Analysis This case is contrary to the concept of conservative management. First, Mrs. B's management involved dialysis therapy. Secondly, there was no shared decision-making or advanced care planning, and a multidisciplinary team was not involved. The care of Mrs. B was not patient-centered because, considering her pre-existing conditions and age, dialysis was not the right treatment option for her. This affected the patient’s HRQoL and function. The care was not holistic, as she presented with other symptoms, such as low hemoglobin, pruritus, and loss of appetite, which were not actively managed. Thus, the main attributes of conservative management were lacking in Mrs. B’s care. Antecedents Walker and Avant (Walker & Avant, 2019 ) describe antecedents as events, conditions, or circumstances that must be present before a concept can occur. Based on the analysis of the reviewed literature, antecedents of conservative management of CKD can be understood as operating across three domains: the patient, the health care provider, and the health care system. Patient-related antecedents include having advanced CKD, older age (typically > 75 years), combined with multiple comorbidities, diminished functional status, a stated preference for conservative management, and knowledge and perception of conservative management (Davison et al., 2015a ; Murtagh et al., 2016 ; Palat et al., 2021 ; Sakthivel et al., 2024 ; Zarantonello et al., 2021a ). Provider-related antecedents reflect clinicians’ beliefs, attitudes, and willingness or motivation to engage patients in discussions about conservative management, as well as their knowledge, capacity, and skills to deliver conservative management (Chawla et al., 2025 ; Lunney et al., 2021 ; Susanto et al., 2018 ). Health system-related antecedents include availability of a well-trained multidisciplinary team, supportive organisational or national policies, adequate system-level infrastructure that accommodates conservative management, the presence of clearly articulated clinical guidelines, emerging evidence demonstrating the effectiveness of conservative approaches, and structured training programmes for health professionals (Chawla et al., 2025 ; Saeed et al., 2020 ; J. S. Scherer et al., 2018 ; Susanto et al., 2018 ). In resource constrained settings, the lack of RRT facilities also serve as an antecedent to conservative management (Lunney et al., 2021 ; Zarantonello et al., 2021a ). Consequences Consequences are defined as events or outcomes that occur as a result of the occurrence of a concept (Walker & Avant, 2019 ). Within the literature, conservative management is associated with both positive and negative consequences. Reported positive consequences include improved overall QoL, better psychological, social, spiritual, and culturally responsive support, reduced symptom burden, decreased caregiver burden and treatment burden, including lower health care costs and fewer hospital visits and hospitalisations. Additionally, patients receiving conservative management often report greater perceived control over their illness and care decisions, and a higher likelihood of dying at their preferred place (Chawla et al., 2025 ; Combs & Davison, 2015 ; Moss et al., 2020 ; Oestreich et al., 2020 ; Subramonian & Frey, 2020 ; Verberne et al., 2021 ). In contrast, a commonly reported negative consequence of conservative management is reduced overall survival when compared with dialysis-based treatment, particularly among younger patient populations (Buur et al., 2021 ; Davison et al., 2015a ; Lunney et al., 2021 ). However, evidence suggests that survival outcomes among older adults, particularly those aged 80 years and above, are comparable between patients receiving conservative management and those undergoing dialysis (Verberne et al., 2018 ). Empirical Referents Empirical referents are classes of phenomena that demonstrate the occurrence of the concept itself (Walker & Avant, 2019 ). In conservative management, empirical referents relate to the measures used to assess the availability and quality of conservative management services. These indicators include the existence of dedicated conservative management clinics, accessibility of conservative care across healthcare settings, availability of established policies, protocols, and clinical guidelines, presence of multidisciplinary teams trained in conservative kidney care, documented patient–provider communication and recorded treatment decisions, structured and ongoing training for healthcare providers, availability of tools to support shared decision-making, standardised processes for proactive symptom assessment and management, including validated symptom burden and QoL instruments, as well as formal structures for delivering psychosocial, spiritual, and culturally appropriate support (Chotivatanapong et al., 2024 ; Davison et al., 2015a , 2024 ; Lunney et al., 2021 ; Okpechi et al., 2022 ; J. Scherer et al., 2020 ; Susanto et al., 2018 ). Discussion Conservative management is a comprehensive approach to care for patients with CKD that is increasingly being adopted, driven by financial constraints in low-income countries and an aging population and the rising prevalence of comorbidities in other settings (Davison et al., 2015a ; Murtagh et al., 2016 ). Despite its growing relevance, it remains inconsistently defined and variably implemented, limiting its recognition, accessibility, and evaluation across health systems (Chotivatanapong et al., 2024 ; Gelfand, 2023 ; Sakthivel et al., 2024 ; J. S. Scherer et al., 2023 ; Susanto et al., 2018 ). Therefore, this concept analysis was conducted to clarify the defining attributes, antecedents, consequences, and empirical referents of conservative management and to provide a structured framework to guide clinical practice, research, and policy. This concept analysis demonstrates that the conservative management of CKD is a multidimensional construct comprising several interrelated attributes that collectively underpin high-quality care. Therefore, effective delivery of conservative management requires the systematic integration of all defining attributes within care programs. However, evidence suggests substantial gaps in its implementation. The 2018 Global Kidney Health Atlas Survey, which assessed the availability, accessibility, and quality of conservative management across 160 countries, indicated that although 81% of the surveyed countries reported offering some form of conservative management, fewer than half consistently implemented the key attributes of the concept. Specifically, only 46% reported the use of multidisciplinary teams, 32% incorporated shared decision-making, and 36% provided psychological, cultural or spiritual support (Lunney et al., 2021 ). Similar patterns have been reported at the national level. In a survey of nephrology clinics in the United States of America (USA), none of the participating centres reported having a formal conservative management protocol or guideline, only 22% had a dedicated nephrologist providing conservative management, and none operated a dedicated conservative management clinic. In addition, there was no consensus on nomenclature, with conservative management variably described as “conservative”, “palliative”, or “supportive”, and “non-dialysis” care (J. S. Scherer et al., 2023 ). Comparable variability was observed in the Netherlands, where practice patterns differed substantially across nephrology departments, and only one of the 21 departments reported having a dedicated conservative care outpatient clinic. In addition, formal training or education in conservative management was largely unavailable (Susanto et al., 2018 ). These gaps are not unexpected, given the absence of a consistently applied definition for conservative management. Variability in terminology and conceptual understanding has been shown to contribute to misperceptions and inconsistent implementation. Without conceptual clarity, essential components of conservative management may be selectively applied or omitted, resulting in fragmented models of care that do not fully address patients’ clinical and supportive care needs across healthcare settings (Chotivatanapong et al., 2024 ; Gelfand, 2023 ; Sakthivel et al., 2024 ; Susanto et al., 2018 ). This concept analysis demonstrates that the adoption and delivery of conservative management are shaped by patient, provider, and health-system level factors. At the patient level, in addition to clinical characteristics of the patient, individuals’ understanding and perceptions of conservative management influence treatment decision-making (Chawla et al., 2025 ; Sakthivel et al., 2024 ). Limited knowledge and misconceptions about conservative management have been reported in the literature. For instance, a qualitative study conducted in a public hospital in the USA found that patients with kidney failure and their families exhibited poor understanding of conservative management and commonly perceived dialysis as the only meaningful treatment option, with non-dialytic care often equated with death (Karlin et al., 2019 ). Such perceptions may constrain informed choices and limit the consideration of conservative management, even when it may be clinically appropriate. Provider-related antecedents refer to clinicians’ knowledge, skills, and capacity to deliver conservative management, as well as their beliefs, attitudes, and willingness to engage patients in discussions about this care option (Chawla et al., 2025 ; Lunney et al., 2021 ; Susanto et al., 2018 ). The literature reports mixed findings regarding healthcare professionals’ attitudes towards conservative management. For example, Scherer et al.(J. S. Scherer et al., 2023 ) reported that most nephrologists in a USA national survey expressed positive attitudes towards conservative management; however, limited formal training constrained their understanding of the concept, which in turn affected its implementation. In contrast, Okamoto et al. (Okamoto et al., 2015 ) in a UK national survey identified that healthcare professionals held predominantly negative attitudes towards conservative management and lacked confidence in providing it, resulting in eligible patients not being offered this option. Despite these differences, both studies, along with a broader body of literature, consistently highlight gaps in provider knowledge and skills, which are largely attributable to the absence of structured education and training. These gaps represent key provider and system-related antecedents that may impede the consistent delivery of conservative management and limit patients’ access to care (Lunney et al., 2021 ; Okamoto et al., 2015 ; Okpechi et al., 2022 ; J. S. Scherer et al., 2023 ; Sota et al., 2024 ; Susanto et al., 2018 ). In low-resource settings, conservative management often functions as the default treatment option for patients with advanced CKD due to limited access to RRT (Davison et al., 2015a , 2024 ; Zarantonello et al., 2021a ). In contrast, in many resource-adequate settings, conservative management is shaped by policy environments that prioritise dialysis over non-dialytic care. Such policies influence clinical norms, provider knowledge, confidence, and treatment practices, thereby limiting the consistent integration of conservative management into routine care. For example, Thailand’s Universal Coverage Scheme designates peritoneal dialysis or haemodialysis as the default treatment for kidney failure, which has been shown to significantly influence clinical decision-making and constrain the systematic adoption of conservative management (Chawla et al., 2025 ). Similarly, in the USA, healthcare policies that position dialysis as the standard treatment hinder the development and implementation of structured conservative management programmes, despite evidence supporting their patient-centred benefits (Oestreich et al., 2020 ). Compounding these policy-level barriers, a limited nephrology workforce remains a major system-level constraint on the provision of comprehensive care for patients with CKD. For instance, the median number of nephrologists in Africa is estimated at 0.62 per million population; range 0.24–1.56 (Okpechi et al., 2022 ). Collectively, dialysis-focused policy frameworks, workforce shortages, and lack of investment in training facilities constitute key system-level antecedents that shape the availability, accessibility, and consistency of conservative management across diverse healthcare contexts. The implementation of conservative management provides important benefits for patients, caregivers, and healthcare systems. This concept analysis indicates that when applied appropriately, most patients with CKD can benefit. Key attributes, such as a multidisciplinary care approach, have been shown to slow disease progression, reduce mortality, decrease the need for renal replacement therapy, and lower healthcare costs (Hsu et al., 2021 ). Comparative studies have demonstrated that QoL outcomes for patients receiving conservative management are similar to those undergoing dialysis, highlighting its viability as a meaningful alternative when dialysis may not align with patient goals (Murtagh et al., 2016 ; Subramonian & Frey, 2020 ). Survival outcomes vary by age; patients younger than 80 years may have lower survival with conservative management than with dialysis, whereas outcomes are comparable for those aged 80 years and older (Verberne et al., 2018 ). Nonetheless, there remains a need for more robust evidence to confirm these outcomes, and the current lack of strong evidence has been reported as a barrier to implementation among some clinicians (Murtagh et al., 2016 ; Okamoto et al., 2015 ; Susanto et al., 2018 ). For caregivers, conservative management can reduce the physical, psychological, and emotional burden associated with intensive dialysis, enhancing family well-being and support (Combs & Davison, 2015 ; Moss et al., 2020 ; Subramonian & Frey, 2020 ). At the system level, it promotes a more efficient use of healthcare resources by reducing hospitalisations, lowering costs, and decreasing reliance on dialysis, particularly in resource-limited settings (Hsu et al., 2021 ). These findings highlight that conservative management is not merely an alternative to dialysis; when systematically implemented, it constitutes a complementary care strategy that aligns with patient preferences, optimises clinical outcomes, and promotes efficient use of healthcare resources. Limitations The results of this concept analysis should be interpreted in the context of several limitations. Firstly, the findings are inherently dependent on the available published literature. Consequently, the findings may be influenced by publication bias or gaps in the available research. Secondly, the process of identifying defining attributes, antecedents, consequences and empirical referents involves the researcher's judgment, which may influence the selection and interpretation of key elements. Finally, as a theoretical approach, concept analysis provides a descriptive rather than empirical understanding, limiting its ability to test causal relationships. Conclusion Conservative management of CKD is a patient-centred, multidimensional approach that complements dialysis in patients with CKD. This concept analysis highlights its key attributes and emphasises that successful implementation requires the alignment of patient readiness, provider competence, and supportive health systems. When applied effectively, conservative management improves QoL, reduces caregiver burden, lowers healthcare costs, and decreases the reliance on RRT. Addressing barriers such as inadequate provider training, workforce shortages, lack of guidelines and dedicated clinics, as well as policies favouring dialysis is essential to expand access. Recognising conservative management as a complementary strategy to dialysis enables the delivery of individualised kidney care worldwide. Relevance to Clinical Practice This concept analysis provides a clear and structured understanding of conservative kidney management, which is essential for its consistent application in clinical practice. By delineating its defining attributes, it offers a practical framework to guide clinicians in delivering comprehensive, non-dialytic care to patients with CKD. The inclusion of model and contrary case studies further strengthens clinical applicability by illustrating how it is appropriately implemented in practice, as well as highlighting common gaps and misconceptions that may hinder its delivery. The findings highlight the importance of addressing key antecedents, including strengthening provider competence through targeted education and training, improving attitudes towards conservative management, and ensuring the availability of system-level supports such as multidisciplinary teams, clinical guidelines, adequate workforce capacity, and enabling policies. Addressing these factors can enhance the quality of conservative management services, leading to improved patient outcomes, including better quality of life, effective symptom control, increased autonomy, reduced caregiver burden, decreased reliance on renal replacement therapy, and lower healthcare costs. In addition, the identified empirical referents offer practical indicators for assessing the implementation and quality of conservative management, thereby supporting ongoing evaluation and improvement of services. Declarations Acknowledgements The authors acknowledge Kamuzu University of Health Sciences, Professor Ingrid Tjoflåt, Dr. Gertrude Mwalabu, and the NORHED II SBE project team for their support of the first author’s PhD studies, which informed this concept analysis. • Conservative management is increasingly recognised as a viable alternative for patients with CKD who are unsuitable for, unable to access, or choose not to undergo dialysis • The concept is not well-defined, which makes it difficult to identify the healthcare needs of patients and systematically study ways to enhance outcomes • The concept analysis has identified the key attributes, antecedents, consequences and empirical references, and had provided a model case, borderline and contrary case to enhance effective implementation References Ashuntantang G, Osafo C, Olowu WA, Arogundade F, Niang A, Porter J, Naicker S, Luyckx VA (2017) Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: A systematic review. 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(CCC:000598229800012) Zarantonello D, Rhee CM, Kalantar-Zadeh K, Brunori G (2021b) Novel conservative management of chronic kidney disease via dialysis-free interventions. Curr Opin Nephrol Hypertens 30(1):97–107 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9289097","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":615791027,"identity":"cb59626a-1de7-4105-b0c6-27e0f940bed8","order_by":0,"name":"Chisomo Mulenga","email":"","orcid":"https://orcid.org/0009-0009-6224-9913","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Chisomo","middleName":"","lastName":"Mulenga","suffix":""},{"id":615801430,"identity":"6e3feb0d-c18e-4952-b680-fb3c83e4b1e5","order_by":1,"name":"Catherine Titanus Mselema","email":"","orcid":"https://orcid.org/0009-0004-6681-9841","institution":"St John of God University","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"Titanus","lastName":"Mselema","suffix":""},{"id":615811264,"identity":"fa1df807-17b0-497b-babd-76a59b409cea","order_by":2,"name":"Felistas Chiundira","email":"","orcid":"https://orcid.org/0009-0000-7522-7590","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Felistas","middleName":"","lastName":"Chiundira","suffix":""},{"id":615811265,"identity":"3e008380-a717-4264-8a27-e64d6839a7d1","order_by":3,"name":"Rodney Masese","email":"","orcid":"https://orcid.org/0009-0004-2155-6312","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rodney","middleName":"","lastName":"Masese","suffix":""},{"id":615811266,"identity":"74a93bdd-8353-4015-9172-49a732c6f556","order_by":4,"name":"Jim Mtambo","email":"","orcid":"https://orcid.org/0000-0003-1422-0795","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Jim","middleName":"","lastName":"Mtambo","suffix":""},{"id":615811267,"identity":"f10458a4-2048-4466-a520-a9a90854ec5c","order_by":5,"name":"Felix Chisoni","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYBAC9gYehgNAmoefh4GNOC08B6BaJHtI0QIGBmeI1sJ+9uDBHxV3ZIzPnDF78OEPgzx/A3eaBF4tPHkJh3nOPOMxO9tjbjizjcFwxgHebXi12EvwGBxmbDvMY3aex0yat4GBcQMD77YbeG0Bajn4E6jFuB+o5c8fBnuitBzgBWox4O0xkwaGQCJhLTw5BkC/HOaROHOsTLK3TSJ5xmHe7T/wamE/Y/zxR8Vhe/6e5G0SP/7Y2Pa39242wKcFHQDDipkU9aNgFIyCUTAKsAIAbMJE9fB0AwcAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-1798-6446","institution":"Kamuzu University of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Felix","middleName":"","lastName":"Chisoni","suffix":""},{"id":615811268,"identity":"24a13beb-c69f-4deb-939c-3169b2406564","order_by":6,"name":"Patrick Mapulanga","email":"","orcid":"https://orcid.org/0000-0002-0305-3736","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"","lastName":"Mapulanga","suffix":""},{"id":615811269,"identity":"59680635-cc2a-4a74-bdab-5589d6567c2b","order_by":7,"name":"Gladys Msiska","email":"","orcid":"https://orcid.org/0000-0001-5606-639X","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Gladys","middleName":"","lastName":"Msiska","suffix":""},{"id":615811270,"identity":"8536aeb3-5744-4cfb-a2ec-d6fb83fd6a86","order_by":8,"name":"Ellen Chirwa","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ellen","middleName":"","lastName":"Chirwa","suffix":""}],"badges":[],"createdAt":"2026-04-01 08:40:31","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9289097/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9289097/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105986138,"identity":"85a62b65-2b82-4aab-a578-ba9c3dffd459","added_by":"auto","created_at":"2026-04-02 07:28:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83198,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Diagram \u003c/strong\u003e(Page et al., 2021)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9289097/v1/551b5637e07fc39fd8c5860e.png"},{"id":105985919,"identity":"a2d9c086-2945-455c-8842-cbf29573897c","added_by":"auto","created_at":"2026-04-02 07:26:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":193623,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAttributes of Conservative Management in CKD\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9289097/v1/760fb2829862475894cec632.png"},{"id":105986414,"identity":"9e2bda05-1e06-4cbe-88a3-cfded81c183d","added_by":"auto","created_at":"2026-04-02 07:28:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1163238,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9289097/v1/35f8405e-c505-40b2-b998-d5d87e48a948.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eConservative Management in Chronic Kidney Disease: A Concept Analysis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic Kidney Disease (CKD) is a significant contributor to the global disease burden and is rapidly becoming a major public health concern (Mohamed Hussin \u0026amp; Syed Jamaludin, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Current estimates indicate that approximately 850\u0026nbsp;million people worldwide suffer from CKD (Bello et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The prevalence of CKD globally is approximately double that of diabetes (422\u0026nbsp;million) and 20 times that of cancer (42\u0026nbsp;million) and HIV/AIDS (36.7\u0026nbsp;million) (Jager et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). CKD progresses through five stages based on the estimated glomerular filtration rate (eGFR) (Lunney et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Earlier stages (1, 2, and 3) may not present any symptoms and can potentially be reversed with medical intervention (Subramonian \u0026amp; Frey, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). CKD stage 4 indicates severe kidney function loss, whereas stage 5 CKD, also called End Stage Kidney Disease (ESKD), is an advanced stage of CKD where there is irreversible loss of kidney function (George et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Notably, the majority of CKD patients (79%) receive their diagnosis during the advanced stages 3\u0026ndash;5, indicating a delayed recognition of the condition and requiring effective medical management (L\u0026oacute;pez et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRenal replacement therapy (RRT), which includes dialysis and kidney transplantation, is the primary treatment for patients with CKD in the final stages of the disease (Lunney et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, RRT is associated with a substantial financial burden, limiting access for many patients in low-resource settings (Ashuntantang et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Ng \u0026amp; Li, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Data from the International Society of Nephrology Global Kidney Health Atlas for Africa (2018) indicate that the annual costs of haemodialysis (HD) and peritoneal dialysis (PD) are prohibitively high, with median annual costs per patient ranging from US\u003cspan\u003e$\u003c/span\u003e5,980 to US\u003cspan\u003e$\u003c/span\u003e22,731 for HD and US\u003cspan\u003e$\u003c/span\u003e6,895 to US\u003cspan\u003e$\u003c/span\u003e34,165 for PD (Okpechi et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Correspondingly, the proportion of patients with stage 5 CKD who are not receiving treatment, including HD, PD, or transplantation, is much higher in Low-Income Countries (LICs) (98%) and LMICs (94%) than in Upper-Middle-Income Countries (UMICs) (79%) and High-Income Countries (HICs) (30%) (Bello et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). On the other hand, RRT may not be suitable for certain populations, such as the elderly and those with multiple comorbidities (Davison et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Zarantonello et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2021b\u003c/span\u003e). Therefore, many countries are increasingly offering conservative management option (Zarantonello et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2021b\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough widely recognised and utilised, conservative management remains a relatively new treatment modality that lacks clear definition (Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e). Despite its popularity, several unknowns remain regarding its optimal adoption in practice and delivery (Murtagh et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The absence of common terminology associated with this approach further compounds the problem, making it difficult to identify the healthcare needs of patients and systematically study ways to enhance care and outcomes (Gelfand, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sakthivel et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Currently, there is no uniformity in the implementation of this option in daily practice (Chotivatanapong et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Susanto et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This concept analysis, therefore, aimed to elucidate the concept of conservative management in the context of CKD by expounding on its defining characteristics, antecedents, and consequences. Furthermore, this analysis presents model, borderline, and contrary cases, and empirical referents to provide a more comprehensive understanding of the concept. This analysis may facilitate the effective implementation of conservative management strategies for CKD.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis study employed Walker and Avant\u0026rsquo;s concept analysis approach. This method involves eight steps: selecting the concept; determining the aims or purpose of the analysis; identifying all uses of the concept; determining the defining attributes; constructing a model case; identifying borderline, related, contrary, invented, and illegitimate cases; identifying antecedents and consequences; and empirical referents (Walker \u0026amp; Avant, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). After selecting the concept and establishing the aim of the analysis, an integrative literature review was conducted to identify the uses of conservative management in the literature and determine its defining attributes, antecedents, and consequences. A model case and other cases were then developed based on the identified attributes, and empirical referents were identified to clarify how the concept could be measured or observed in practice.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eA comprehensive literature search was conducted using the PubMed, Embase, Scopus, Web of Science, and Google Scholar electronic databases. Manual searches of the reference lists of the relevant articles were also performed to identify additional eligible studies. The search strategy was guided by the Population, Concept, and Context (PCC) framework, as recommended by the Joanna Briggs Institute (Peters et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e); (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Boolean operators (AND, OR) were used to combine keywords to ensure the comprehensive retrieval of relevant literature.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePCC Framework\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCC Element\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription / Key Concepts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRelated Terms\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePopulation (P)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdults diagnosed with Chronic Kidney Disease (CKD), especially those in stages 3\u0026ndash;5, including those not eligible for, unable to access or choosing not to undergo dialysis or kidney transplantation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChronic Renal Failure (CRF), Chronic Kidney Disease (CKD), End-Stage Kidney Disease (ESKD / ESRD), Chronic Renal Insufficiency, Chronic Kidney Insufficiency, Advanced Kidney Disease, Non-dialysis CKD patients, Elderly CKD patients, Patients declining dialysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConcept (C)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eConservative Management\u003c/b\u003e: A patient-centred, non-dialytic approach to care that focuses on symptom control, psychosocial and spiritual support, and advanced care planning.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-dialytic management, Conservative kidney management, Conservative care pathway, Non-renal replacement therapy, Palliative renal care, Supportive kidney care, Integrated palliative nephrology, Symptom management in CKD, Kidney supportive care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContext (C)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSettings and circumstances\u003c/b\u003e where conservative management is provided within healthcare systems, palliative care programs, or community-based environments, especially in resource-limited settings.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary care settings, Nephrology clinics, Hospice and palliative care units, Community-based care, End-of-life care settings, Outpatient management, Home-based renal care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eArticles were included if they focused on conservative management, were published in English between 2015 and 2025, and had their full texts available. Studies were excluded if they were published before 2015, lacked clearly stated aims or methodology, were inaccessible in full text, or contained incomplete data, such as protocols for systematic or scoping reviews.\u003c/p\u003e\n\u003ch3\u003eStudy Selection\u003c/h3\u003e\n\u003cp\u003eAll retrieved records were imported into the Rayyan app (Ouzzani et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) for duplicate removal and screening. After the duplicate records were removed, the remaining articles were screened against the inclusion criteria based on their titles and abstracts, and the full texts of potentially eligible articles were retrieved for detailed assessment. The initial search yielded 213 articles, of which 157 remained after the duplicates were removed. A total of 84 articles were excluded after screening the titles and abstracts. A full-text review of the remaining 73 articles led to the exclusion of 54 articles that did not meet the eligibility criteria. The final analysis included 19 studies (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and Appendix 1.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eCharting Data and Collating Results\u003c/h3\u003e\n\u003cp\u003eA data extraction sheet (Appendix 1) was developed to systematically chart the relevant details from the eligible studies. The sheet captured information including author, year, and country, study aim, key results (attributes, antecedents, consequences, and empirical referents), and the term(s) used for the concept. The extracted data were then collated, compared, and synthesised to identify common patterns and variations across studies, facilitating the delineation of the defining attributes, antecedents, consequences, and empirical referents of conservative management in CKD.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eIdentifying all Uses of the Concept\u003c/h2\u003e \u003cp\u003eConservative management is a term that combines two distinct concepts: \"conservative\" and \"management.\u0026rdquo; According to the Merriam-Webster Dictionary (Merriam-Webster, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), conservative means not extreme or drastic, and is intended to preserve or restore function. In contrast, management refers to an approach to healthcare delivery that focuses on the complex needs of patients and prioritises the coordination of all necessary services (Farlex Partner Medical Dictionary, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Therefore, conservative management is an approach to patient care that involves avoiding intrusive measures, such as surgery or other invasive procedures, usually with the intent to preserve function or body parts (kellybrendel, 2021).\u003c/p\u003e \u003cp\u003eIn relation to CKD, Lunney et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) defined conservative management as an alternative therapy for kidney failure that prioritises symptom management, psychological health, spiritual care, and support from family and society. In this case, the use of an alternative implies that it is a substitute for RRT. Combs and Davison (Combs \u0026amp; Davison, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) defined conservative management as a comprehensive plan that combines palliative care principles with interventions to slow CKD progression and reduce complications without the need for dialysis. The plan includes several elements, such as advance care planning (ACP), completing advance directives or physician orders for life-sustaining treatments, aggressive symptom management, emotional support for both patients and their families, shared decision-making, and involvement of a multidisciplinary team (Combs \u0026amp; Davison, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo address misconceptions about conservative management, the Kidney Disease: Improving Global Outcomes (KDIGO) conference recommended the use of the term comprehensive conservative care (Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e). They further defined the concept as a holistic, patient-centred approach that includes interventions to delay the progression of kidney disease, minimise the risk of complications, and involve shared decision-making, active symptom management, detailed communication (including advance care planning), psychological support, social and family support, and cultural and spiritual support without dialysis (Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e). Similarly, Subramonian and Frey (Subramonian \u0026amp; Frey, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) defined conservative management by focusing on the clinical effectiveness of this approach. They defined conservative management as an approach that involves comprehensive non-dialysis care that aims to prolong kidney function, manage symptoms associated with acidosis, anaemia, bone and mineral metabolism, and blood pressure, and provide dietary support. This approach also involves individualising care by offering shared decision-making and psychological, social, and spiritual support to the patients.\u003c/p\u003e \u003cp\u003eMurakami et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) defined conservative management as active medical management of advanced CKD without dialysis, focusing on delaying the worsening of kidney disease and minimising the symptom burden. Davison et al. (Davison et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) in a study aimed at making recommendations on the care of patients on conservative management, identified the crucial components of conservative kidney management. These include: effective communication, shared decision-making, advance care planning, and psychosocial support. The recommendations also underscore the significance of preserving physical, cognitive, and kidney functions while simultaneously addressing the symptoms. Sakthivel et al. (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) discussed conservative management in terms of the aim, which is to manage symptoms and delay disease progression without dialysis; and management, which involves active medical and lifestyle interventions, such as medications, and dietary modifications.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurrogate Terms\u003c/h3\u003e\n\u003cp\u003eVarious alternative terms have been used to describe conservative management for CKD. For example, in the United Kingdom (UK), common alternative terms include maximum conservative management, conservative kidney care, and palliative kidney care (Okamoto et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The Renal Physicians Association Shared Decision-Making Guideline refers to it as \"active medical management without dialysis,\" while the KDIGO recommends the term \"comprehensive conservative care (Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e).\" Other terms such as renal supportive care, supportive care, and end-of-life care have also been used interchangeably with conservative management (Murtagh et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the other aforementioned names mean the same thing as conservative management, the use of terms like \"supportive care\" end-of-life care, and \"palliative care\" synonymously with conservative management is problematic and confusing, according to Murtagh et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Kidney supportive care refers to services intended to improve the quality of life of patients of any age with established CKD. These services can be provided alongside treatments that aim to prolong life, such as dialysis (Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e). Although end-of-life care shares the same philosophy, it is typically limited to patients who are believed to be within months of death and fall under the larger umbrella of supportive care (Prabhu et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Palliative care is an approach that aims to improve the quality of life of patients, including adults and children, and their families, who are experiencing problems associated with life-threatening illnesses. It involves the early identification, correct assessment, and treatment of pain and other physical, psychosocial, and spiritual problems to prevent and relieve suffering (World Health Organization, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Palliative care can be provided together with therapies intended to prolong life, including dialysis, and focuses on the relief of suffering, whether the patient is on dialysis or not (Belino et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Kidney supportive care, end-of-life care, and palliative care are umbrella terms encompassing all aspects of management, including conservative management and RRT. Therefore, conservative management should not be used synonymously, as it specifically focuses on non-dialysis treatment.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOperational Definition of Conservative Management\u003c/h2\u003e \u003cp\u003eConservative management is comprehensive and individualised non-dialysis patient care that involves a multidisciplinary approach, shared decision-making, advance care planning, proactive symptom identification and management, and patient and family support to enhance patients\u0026rsquo; health-related quality of life.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDefining Attributes of Conservative Management in Chronic Kidney Disease\u003c/h2\u003e \u003cp\u003eLiterature review led to the identification of nine attributes, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The attributes include: holistic approach to care, patient-centred care, advance care planning, shared decision-making, multidisciplinary care, proactive symptom recognition and management, preservation of functional status (cognitive, physical, and kidney), non-dialytic management, and sustained patient and family support (psychological, social, spiritual, and cultural).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHolistic Approach to Care\u003c/h2\u003e \u003cp\u003eHolistic care is complete or total patient care that considers the physical, emotional, social, economic, and spiritual needs of the person, their response to the illness, and the effect of the illness on their ability to meet self-care needs (Ventegodt et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Chronic kidney disease and its treatment affect all dimensions of a patient\u0026rsquo;s life and consequently their QoL (Yapa et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Therefore, a holistic approach to care would ensure that patients experience a high QoL.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePatient-Centered Care\u003c/h2\u003e \u003cp\u003ePatient-centred care respects and responds to individual patient preferences, needs, and values, ensuring that patient values guide all clinical decisions (Freidin et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). A patient-centred approach is preferable over a disease-based approach when managing CKD because patients with CKD often suffer from multiple chronic conditions, which may require different and sometimes conflicting treatments and targets. Moreover, each patient may have different priorities and values regarding treatment outcomes. Therefore, the potential benefits and risks of a particular treatment can vary significantly among patients (Eilers, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Freidin et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Under a patient-centred approach, medical evidence and knowledge are evaluated in the unique context of the person being cared for and applied judiciously to uphold what is important to them (Freidin et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAdvance Care Planning\u003c/h2\u003e \u003cp\u003eAdvanced care planning is a communication process that leads to decisions about the goals of future care and requires provider input on prognosis, options for care, and assurance of ongoing management, regardless of the choices made (Raghavan \u0026amp; Holley, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The unpredictable illness trajectories of CKD and progressive cognitive decline highlight the importance of early ACP with ongoing communication and re-evaluation throughout the illness to ensure that end-of-life crises are avoided and that care remains consistent with patients\u0026rsquo; wishes (Holley, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). ACP allows for smooth transitions between illness progression, choice of treatment, and wishes for family and everyday life (Frandsen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Some issues addressed in advance care planning include the choice of treatment options and end-of-life preferences, such as the place of death (Moss et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eShared Decision Making\u003c/h2\u003e \u003cp\u003eShared decision-making is a patient-centred approach in which choices are viewed within the explicitly discussed values and preferences of the patient (Davis \u0026amp; Davison, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In shared decision-making, decisions about RRT modalities or conservative management are made jointly with the patient, their family members, and the healthcare team, considering the predicted quality of life, predicted life expectancy, the patient\u0026rsquo;s preferences, and other factors, such as co-existing conditions (National Institute for Health and Care, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The goal of shared decision-making is to align treatment with patient and family goals, values, preferences, and medical concerns (Davison et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015a\u003c/span\u003e; Subramonian \u0026amp; Frey, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) Specifically, designed patient decision aids / tools are used to facilitate discussion (Davis \u0026amp; Davison, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eMultidisciplinary Care\u003c/h2\u003e \u003cp\u003eConsidering the diverse needs of patients with CKD and the complexity of the condition, a multidisciplinary approach is required to provide comprehensive and continuous care (Hsu et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The multidisciplinary team may comprise the following: nephrologists, general practitioners, nurses, psychosocial workers, counselors or psychologists, dieticians, pharmacists, allied health professionals, chaplains, family doctors, community staff/health-care volunteers depending on the country and region (Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e; Hsu et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Palat et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Each of these team members has distinct roles; for instance, the nephrologist is responsible for medical management, nurses focus on providing CKD-related health education and guiding lifestyle changes, dieticians provide dietary counselling, and psychologists focus on mental health issues affecting the patient and caregivers (Hsu et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Additional training or expertise in comprehensive conservative care is recommended for all healthcare workers involved in renal medicine (Palat et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eProactive Symptom Recognition and Management\u003c/h2\u003e \u003cp\u003ePatients with CKD stage 5 have a high symptom burden caused by factors related to the disease process (metabolic derangements) and comorbidities (Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e; Moss et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Murtagh et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). According to Murtagh et al. (Murtagh et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) the number of symptoms may range from 6.8 to 17 per patient. Therefore, proactive symptom recognition and management are integral aspects of conservative management (Moss et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Raghavan \u0026amp; Holley, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Both non-pharmacological and pharmacological strategies are used to manage the symptoms (Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePreservation of Functional Status (cognitive, physical, and kidney)\u003c/h2\u003e \u003cp\u003eThe goals of CKD managementare to slow disease progression and preserve kidney function, which ultimately promotes the HRQoL (Kalantar-Zadeh et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Health-related quality of life has four dimensions: physical, psychological, emotional, and social (Song, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Therefore, the preservation of function applies to all the dimensions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eNon-dialytic Management\u003c/h2\u003e \u003cp\u003eConservative management is sometimes referred to as active medical management without dialysis, as it focuses only on pharmacological and non-pharmacological interventions (Moss et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This attribute is a key feature in differentiating conservative management from other terms, such as supportive care, end-of-life care, and palliative care, which are sometimes erroneously used interchangeably with conservative management (Belino et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Davison et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSustained Patient and Family support\u003c/h2\u003e \u003cp\u003ePatients with CKD are exposed to multiple physical and psychosocial stressors due to the illness (Yapa et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The biopsychosocial impact of CKD has been proposed to account for poorer QoL compared to that of patients with other chronic diseases (Bale et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Furthermore, survey data have shown a significant correlation between poor QoL and higher morbidity and mortality in patients with ESKD (Song, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Thus, Patients with CKD and their families need sustained support in all domains of life. Increased social support has the potential to positively affect outcomes through several mechanisms, including decreased levels of depressive effects, increased patient perception of QoL, increased access to healthcare, increased patient compliance with prescribed therapies, and direct physiological effects on the immune system (Bale et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eModel Case\u003c/h2\u003e \u003cp\u003eWalker and Avant (Walker \u0026amp; Avant, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) define a model case as an example that demonstrates all the defining attributes of a concept. This is a case of Mr. X, a 75-year-old man, who presented to the hospital with complaints of fatigue, loss of appetite, vomiting, reduced urine output, leg swelling and shortness of breath. The patient had a history of hypertension and type 1 diabetes mellitus. The blood pressure was 170/100 mmHg, the random blood sugar level was 450 mg/dl, and the haemoglobin level was 8 g/dl. His eGFR was 10 mL/min/1.73m\u0026sup2;, and ESKD was diagnosed. He was prescribed medication to manage his blood pressure, anaemia, fluid overload, and vomiting, and to control his blood sugar level. He was educated on lifestyle changes. A team of healthcare professionals, including a nephrologist, nurse, dietician, psychologist, and clergy, was involved in Mr. X's care. The patient\u0026rsquo;s family was included in the care plan. Mr. X\u0026rsquo;s nephrologist and nurse discussed the treatment options available for ESKD with him and his family. The team considered various factors, such as Mr. X's age, pre-existing health conditions, predicted quality of life, life expectancy, and personal preferences. Decision aids were used to assist the team in making the appropriate choices. Considering these factors, the team agreed that conservative management would be the best course of action for Mr. X, who was advised to indicate his future treatment preferences. Mr. X and his family were also referred to renal support groups in their communities. Mr. X was regularly followed up at the clinic, where the assessment findings indicated that his overall HRQoL had improved.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eThis case exemplifies the effective implementation of conservative management strategies. Mr. X\u0026rsquo;s care encompassed all aspects of his life, including the physical, psychological, social, and spiritual dimensions, exhibiting a holistic approach. The management plan was tailored to Mr. X's specific symptoms, characteristics, and preferences, reflecting a patient-centred approach with active symptom recognition and management. The decision-making process is shared among Mr. X, his family, the nephrologist, and the nurse, with advance care planning in place. A multidisciplinary team was involved in the management of Mr. X. Non-dialysis treatment was chosen to manage the patient\u0026rsquo;s symptoms and preserve function. Support was provided to Mr. X and his family, including necessary information and referrals to support groups. The ultimate goal of this approach was to enhance Mr. X's QoL and optimise his overall well-being, which was evident during follow-up care.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eBorderline Case\u003c/h2\u003e \u003cp\u003eA borderline case contains most of the defining attributes of the concept being examined, but not all of them (Walker \u0026amp; Avant, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Mr P, 45 years old, presented to the hospital with complaints of shortness of breath, fatigue, reduced urine output, generalised oedema, nausea, and reduced appetite. The patient had a history of heart failure. On assessment, the pulse rate was 110 beats per minute, the respiration rate was 28 breaths per minute, blood pressure was 160/90 mmHg, and oxygen saturation was 96%. His haemoglobin level was 8.5 g/dl, and the eGFR was 13 mL/min/1.73m\u0026sup2;; therefore ESKD was diagnosed. He was prescribed medications to manage his blood pressure, anaemia, fluid overload, and loss of appetite. Mr P was managed by physicians, nurses, dieticians, and social workers. The patient\u0026rsquo;s family was also included in the care plan. Mr. P's physician informed him and his family about conservative management as a treatment plan. Mr. P and his family were referred to renal support groups within their community to ensure that they receive the necessary support.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eThis case fits well within the context of borderline cases. Mr. P received individualised care based on his presenting complaints from a multidisciplinary team available in the setting. He was placed on non-dialysis management and received support from his family. However, shared decision-making and advance care planning, which are important attributes of conservative management, were not implemented.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eContrary Case\u003c/h2\u003e \u003cp\u003eA contrary case does not reflect the concept (Walker \u0026amp; Avant, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Mrs. B, aged 76 years, presented to the hospital with complaints of general body weakness, reduced urine output, oedema of the lower extremities, pruritus, loss of appetite, and poor general health for the past 6 months. Mrs. B was HIV-positive and had been receiving antiretroviral therapy for 30 years. She also had a history of hypertension, heart failure, and type 1 diabetes mellitus. Upon assessment, her blood pressure was 180/ 100 mmHg, CD4 count was 400 cells/mm^3, random blood sugar was 400 mg/dl, heamoglobin was 7 g/dl, and her estimated glomerular filtration rate was 8 mol/min/173. Mrs B. was diagnosed with ESKD. Mrs. B was told to continue taking her current medication. The admitting doctor, who is a general practitioner, informed Mrs. B and her husband, who accompanied her to the hospital about her diagnosis and the need to initiate hemodialysis. No explanations were provided regarding the available options or the advantages and disadvantages of each option. Multidisciplinary team members were not involved in the care, apart from the nurses in the ward, who were just told what to do. Mrs. B was initiated on dialysis three times a week, but after having a few sessions, she failed to cope with the treatment as she developed other dialysis-related symptoms. Mrs. B and her husband decided to stop dialysis and spend the remaining days at home with family.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eThis case is contrary to the concept of conservative management. First, Mrs. B's management involved dialysis therapy. Secondly, there was no shared decision-making or advanced care planning, and a multidisciplinary team was not involved. The care of Mrs. B was not patient-centered because, considering her pre-existing conditions and age, dialysis was not the right treatment option for her. This affected the patient\u0026rsquo;s HRQoL and function. The care was not holistic, as she presented with other symptoms, such as low hemoglobin, pruritus, and loss of appetite, which were not actively managed. Thus, the main attributes of conservative management were lacking in Mrs. B\u0026rsquo;s care.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eAntecedents\u003c/h2\u003e \u003cp\u003eWalker and Avant (Walker \u0026amp; Avant, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) describe antecedents as events, conditions, or circumstances that must be present before a concept can occur. Based on the analysis of the reviewed literature, antecedents of conservative management of CKD can be understood as operating across three domains: the patient, the health care provider, and the health care system. Patient-related antecedents include having advanced CKD, older age (typically\u0026thinsp;\u0026gt;\u0026thinsp;75 years), combined with multiple comorbidities, diminished functional status, a stated preference for conservative management, and knowledge and perception of conservative management (Davison et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015a\u003c/span\u003e; Murtagh et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Palat et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Sakthivel et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Zarantonello et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e). Provider-related antecedents reflect clinicians\u0026rsquo; beliefs, attitudes, and willingness or motivation to engage patients in discussions about conservative management, as well as their knowledge, capacity, and skills to deliver conservative management (Chawla et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lunney et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Susanto et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Health system-related antecedents include availability of a well-trained multidisciplinary team, supportive organisational or national policies, adequate system-level infrastructure that accommodates conservative management, the presence of clearly articulated clinical guidelines, emerging evidence demonstrating the effectiveness of conservative approaches, and structured training programmes for health professionals (Chawla et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Saeed et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; J. S. Scherer et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Susanto et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In resource constrained settings, the lack of RRT facilities also serve as an antecedent to conservative management (Lunney et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Zarantonello et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2021a\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eConsequences\u003c/h2\u003e \u003cp\u003eConsequences are defined as events or outcomes that occur as a result of the occurrence of a concept (Walker \u0026amp; Avant, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Within the literature, conservative management is associated with both positive and negative consequences. Reported positive consequences include improved overall QoL, better psychological, social, spiritual, and culturally responsive support, reduced symptom burden, decreased caregiver burden and treatment burden, including lower health care costs and fewer hospital visits and hospitalisations. Additionally, patients receiving conservative management often report greater perceived control over their illness and care decisions, and a higher likelihood of dying at their preferred place (Chawla et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Combs \u0026amp; Davison, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Moss et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Oestreich et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Subramonian \u0026amp; Frey, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Verberne et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In contrast, a commonly reported negative consequence of conservative management is reduced overall survival when compared with dialysis-based treatment, particularly among younger patient populations (Buur et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Davison et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015a\u003c/span\u003e; Lunney et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, evidence suggests that survival outcomes among older adults, particularly those aged 80 years and above, are comparable between patients receiving conservative management and those undergoing dialysis (Verberne et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEmpirical Referents\u003c/h3\u003e\n\u003cp\u003eEmpirical referents are classes of phenomena that demonstrate the occurrence of the concept itself (Walker \u0026amp; Avant, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In conservative management, empirical referents relate to the measures used to assess the availability and quality of conservative management services. These indicators include the existence of dedicated conservative management clinics, accessibility of conservative care across healthcare settings, availability of established policies, protocols, and clinical guidelines, presence of multidisciplinary teams trained in conservative kidney care, documented patient\u0026ndash;provider communication and recorded treatment decisions, structured and ongoing training for healthcare providers, availability of tools to support shared decision-making, standardised processes for proactive symptom assessment and management, including validated symptom burden and QoL instruments, as well as formal structures for delivering psychosocial, spiritual, and culturally appropriate support (Chotivatanapong et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Davison et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015a\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Lunney et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Okpechi et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; J. Scherer et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Susanto et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eConservative management is a comprehensive approach to care for patients with CKD that is increasingly being adopted, driven by financial constraints in low-income countries and an aging population and the rising prevalence of comorbidities in other settings (Davison et al., \u003cspan class=\"CitationRef\"\u003e2015a\u003c/span\u003e; Murtagh et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Despite its growing relevance, it remains inconsistently defined and variably implemented, limiting its recognition, accessibility, and evaluation across health systems (Chotivatanapong et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Gelfand, \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sakthivel et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; J. S. Scherer et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Susanto et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Therefore, this concept analysis was conducted to clarify the defining attributes, antecedents, consequences, and empirical referents of conservative management and to provide a structured framework to guide clinical practice, research, and policy.\u003c/p\u003e \u003cp\u003eThis concept analysis demonstrates that the conservative management of CKD is a multidimensional construct comprising several interrelated attributes that collectively underpin high-quality care. Therefore, effective delivery of conservative management requires the systematic integration of all defining attributes within care programs. However, evidence suggests substantial gaps in its implementation. The 2018 Global Kidney Health Atlas Survey, which assessed the availability, accessibility, and quality of conservative management across 160 countries, indicated that although 81% of the surveyed countries reported offering some form of conservative management, fewer than half consistently implemented the key attributes of the concept. Specifically, only 46% reported the use of multidisciplinary teams, 32% incorporated shared decision-making, and 36% provided psychological, cultural or spiritual support (Lunney et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSimilar patterns have been reported at the national level. In a survey of nephrology clinics in the United States of America (USA), none of the participating centres reported having a formal conservative management protocol or guideline, only 22% had a dedicated nephrologist providing conservative management, and none operated a dedicated conservative management clinic. In addition, there was no consensus on nomenclature, with conservative management variably described as “conservative”, “palliative”, or “supportive”, and “non-dialysis” care (J. S. Scherer et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). Comparable variability was observed in the Netherlands, where practice patterns differed substantially across nephrology departments, and only one of the 21 departments reported having a dedicated conservative care outpatient clinic. In addition, formal training or education in conservative management was largely unavailable (Susanto et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese gaps are not unexpected, given the absence of a consistently applied definition for conservative management. Variability in terminology and conceptual understanding has been shown to contribute to misperceptions and inconsistent implementation. Without conceptual clarity, essential components of conservative management may be selectively applied or omitted, resulting in fragmented models of care that do not fully address patients’ clinical and supportive care needs across healthcare settings (Chotivatanapong et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Gelfand, \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sakthivel et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Susanto et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis concept analysis demonstrates that the adoption and delivery of conservative management are shaped by patient, provider, and health-system level factors. At the patient level, in addition to clinical characteristics of the patient, individuals’ understanding and perceptions of conservative management influence treatment decision-making (Chawla et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; Sakthivel et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e). Limited knowledge and misconceptions about conservative management have been reported in the literature. For instance, a qualitative study conducted in a public hospital in the USA found that patients with kidney failure and their families exhibited poor understanding of conservative management and commonly perceived dialysis as the only meaningful treatment option, with non-dialytic care often equated with death (Karlin et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Such perceptions may constrain informed choices and limit the consideration of conservative management, even when it may be clinically appropriate.\u003c/p\u003e \u003cp\u003eProvider-related antecedents refer to clinicians’ knowledge, skills, and capacity to deliver conservative management, as well as their beliefs, attitudes, and willingness to engage patients in discussions about this care option (Chawla et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lunney et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Susanto et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). The literature reports mixed findings regarding healthcare professionals’ attitudes towards conservative management. For example, Scherer et al.(J. S. Scherer et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e) reported that most nephrologists in a USA national survey expressed positive attitudes towards conservative management; however, limited formal training constrained their understanding of the concept, which in turn affected its implementation. In contrast, Okamoto et al. (Okamoto et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e) in a UK national survey identified that healthcare professionals held predominantly negative attitudes towards conservative management and lacked confidence in providing it, resulting in eligible patients not being offered this option. Despite these differences, both studies, along with a broader body of literature, consistently highlight gaps in provider knowledge and skills, which are largely attributable to the absence of structured education and training. These gaps represent key provider and system-related antecedents that may impede the consistent delivery of conservative management and limit patients’ access to care (Lunney et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Okamoto et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e; Okpechi et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; J. S. Scherer et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sota et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Susanto et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn low-resource settings, conservative management often functions as the default treatment option for patients with advanced CKD due to limited access to RRT (Davison et al., \u003cspan class=\"CitationRef\"\u003e2015a\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Zarantonello et al., \u003cspan class=\"CitationRef\"\u003e2021a\u003c/span\u003e). In contrast, in many resource-adequate settings, conservative management is shaped by policy environments that prioritise dialysis over non-dialytic care. Such policies influence clinical norms, provider knowledge, confidence, and treatment practices, thereby limiting the consistent integration of conservative management into routine care. For example, Thailand’s Universal Coverage Scheme designates peritoneal dialysis or haemodialysis as the default treatment for kidney failure, which has been shown to significantly influence clinical decision-making and constrain the systematic adoption of conservative management (Chawla et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). Similarly, in the USA, healthcare policies that position dialysis as the standard treatment hinder the development and implementation of structured conservative management programmes, despite evidence supporting their patient-centred benefits (Oestreich et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Compounding these policy-level barriers, a limited nephrology workforce remains a major system-level constraint on the provision of comprehensive care for patients with CKD. For instance, the median number of nephrologists in Africa is estimated at 0.62 per million population; range 0.24–1.56 (Okpechi et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). Collectively, dialysis-focused policy frameworks, workforce shortages, and lack of investment in training facilities constitute key system-level antecedents that shape the availability, accessibility, and consistency of conservative management across diverse healthcare contexts.\u003c/p\u003e \u003cp\u003eThe implementation of conservative management provides important benefits for patients, caregivers, and healthcare systems. This concept analysis indicates that when applied appropriately, most patients with CKD can benefit. Key attributes, such as a multidisciplinary care approach, have been shown to slow disease progression, reduce mortality, decrease the need for renal replacement therapy, and lower healthcare costs (Hsu et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Comparative studies have demonstrated that QoL outcomes for patients receiving conservative management are similar to those undergoing dialysis, highlighting its viability as a meaningful alternative when dialysis may not align with patient goals (Murtagh et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Subramonian \u0026amp; Frey, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Survival outcomes vary by age; patients younger than 80 years may have lower survival with conservative management than with dialysis, whereas outcomes are comparable for those aged 80 years and older (Verberne et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Nonetheless, there remains a need for more robust evidence to confirm these outcomes, and the current lack of strong evidence has been reported as a barrier to implementation among some clinicians (Murtagh et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Okamoto et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e; Susanto et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). For caregivers, conservative management can reduce the physical, psychological, and emotional burden associated with intensive dialysis, enhancing family well-being and support (Combs \u0026amp; Davison, \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e; Moss et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; Subramonian \u0026amp; Frey, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). At the system level, it promotes a more efficient use of healthcare resources by reducing hospitalisations, lowering costs, and decreasing reliance on dialysis, particularly in resource-limited settings (Hsu et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). These findings highlight that conservative management is not merely an alternative to dialysis; when systematically implemented, it constitutes a complementary care strategy that aligns with patient preferences, optimises clinical outcomes, and promotes efficient use of healthcare resources.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eThe results of this concept analysis should be interpreted in the context of several limitations. Firstly, the findings are inherently dependent on the available published literature. Consequently, the findings may be influenced by publication bias or gaps in the available research. Secondly, the process of identifying defining attributes, antecedents, consequences and empirical referents involves the researcher's judgment, which may influence the selection and interpretation of key elements. Finally, as a theoretical approach, concept analysis provides a descriptive rather than empirical understanding, limiting its ability to test causal relationships.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eConservative management of CKD is a patient-centred, multidimensional approach that complements dialysis in patients with CKD. This concept analysis highlights its key attributes and emphasises that successful implementation requires the alignment of patient readiness, provider competence, and supportive health systems. When applied effectively, conservative management improves QoL, reduces caregiver burden, lowers healthcare costs, and decreases the reliance on RRT. Addressing barriers such as inadequate provider training, workforce shortages, lack of guidelines and dedicated clinics, as well as policies favouring dialysis is essential to expand access. Recognising conservative management as a complementary strategy to dialysis enables the delivery of individualised kidney care worldwide.\u003c/p\u003e \u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003eRelevance to Clinical Practice\u003c/h2\u003e \u003cp\u003eThis concept analysis provides a clear and structured understanding of conservative kidney management, which is essential for its consistent application in clinical practice. By delineating its defining attributes, it offers a practical framework to guide clinicians in delivering comprehensive, non-dialytic care to patients with CKD. The inclusion of model and contrary case studies further strengthens clinical applicability by illustrating how it is appropriately implemented in practice, as well as highlighting common gaps and misconceptions that may hinder its delivery. The findings highlight the importance of addressing key antecedents, including strengthening provider competence through targeted education and training, improving attitudes towards conservative management, and ensuring the availability of system-level supports such as multidisciplinary teams, clinical guidelines, adequate workforce capacity, and enabling policies. Addressing these factors can enhance the quality of conservative management services, leading to improved patient outcomes, including better quality of life, effective symptom control, increased autonomy, reduced caregiver burden, decreased reliance on renal replacement therapy, and lower healthcare costs. In addition, the identified empirical referents offer practical indicators for assessing the implementation and quality of conservative management, thereby supporting ongoing evaluation and improvement of services.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ccite\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/cite\u003e\u003c/p\u003e\n\u003cp\u003e\u003ccite\u003eThe authors acknowledge Kamuzu University of Health Sciences, Professor Ingrid Tjofl\u0026aring;t, Dr. Gertrude Mwalabu, and the NORHED II SBE project team for their support of the first author\u0026rsquo;s PhD studies, which informed this concept analysis.\u003c/cite\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u0026bull; Conservative management is increasingly recognised as a viable alternative for patients with CKD who are unsuitable for, unable to access, or choose not to undergo dialysis\u003c/p\u003e\n \u003cp\u003e\u0026bull; The concept is not well-defined, which makes it difficult to identify the healthcare needs of patients and systematically study ways to enhance outcomes\u003c/p\u003e\n \u003cp\u003e\u0026bull; The concept analysis has identified the key attributes, antecedents, consequences and empirical references, and had provided a model case, borderline and contrary case to enhance effective implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAshuntantang G, Osafo C, Olowu WA, Arogundade F, Niang A, Porter J, Naicker S, Luyckx VA (2017) Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: A systematic review. 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J Ren Care\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZarantonello D, Rhee CM, Kalantar-Zadeh K, Brunori G (2021a) Novel conservative management of chronic kidney disease via dialysis-free interventions. Curr Opin Nephrol Hypertens 30(1):97\u0026ndash;107. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/MNH.0000000000000670\u003c/span\u003e\u003cspan address=\"10.1097/MNH.0000000000000670\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. (CCC:000598229800012)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZarantonello D, Rhee CM, Kalantar-Zadeh K, Brunori G (2021b) Novel conservative management of chronic kidney disease via dialysis-free interventions. Curr Opin Nephrol Hypertens 30(1):97\u0026ndash;107\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Kamuzu University of Health Sciences","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chronic Kidney Disease, End-Stage Kidney Disease, CKD, ESKD, Conservative Management, Conservative Care, Conservative Kidney Management","lastPublishedDoi":"10.21203/rs.3.rs-9289097/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9289097/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Conservative management for patients with Chronic Kidney Disease (CKD) is recognized as a viable alternative for patients who are unsuitable for, unable to access, or choose not to undergo dialysis. However, this concept is not well-defined, which affects its application. This study aims to clarify the concept of conservative management in the context of CKD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA concept analysis was conducted using Walker and Avant’s framework. Literature search was conducted across various databass. After screening, nineteen articles met the inclusion criteria and were included in the analysis. Data were analysed to identify attributes, antecedents, consequences, and empirical referents of conservative management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Antecedents were identified at the patient, provider, and health system levels. The consequences include improved quality of life for patients and caregivers, reduced hospital utilisation and healthcare costs, and enhanced patient control over illness, despite a comparatively limited survival benefit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eConservative management is a key alternative care pathway for individuals with advanced CKD. It could lead to improved quality of life, reduced treatment burden, and enhanced patient autonomy, although survival benefits appear to be limited\u003c/p\u003e","manuscriptTitle":"Conservative Management in Chronic Kidney Disease: A Concept Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-02 07:24:06","doi":"10.21203/rs.3.rs-9289097/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b370dded-78d2-4f23-b5bf-b22847f89a4c","owner":[],"postedDate":"April 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65530037,"name":"Nursing"}],"tags":[],"updatedAt":"2026-04-02T07:24:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-02 07:24:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9289097","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9289097","identity":"rs-9289097","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}