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Draft: not yet reviewed by a clinician

Use this page to prepare questions for your care team. It does not replace their advice. Your own targets and doses come from your nephrologist, diabetes team and renal dietitian.

Choosing a treatment for kidney failure

In short

When kidneys fail, there are three paths: a kidney transplant, dialysis (at a center or at home), or comprehensive conservative care (care without dialysis). All three are real choices, and your kidney team should explain each one to you (KDIGO 2024, practice points 5.5.1–5.5.2). No option is best for everyone. The right one fits your health, your daily life and what matters most to you. Start learning at stage G4, while you still feel fairly well and have time to choose (KDOQI vascular access, statement 6.1). If a choice stops working for you, you can change it later (NIDDK).

Your numbers: the planning timeline

When What happens Source
eGFR 30 or less (G4) and falling Learn about every option, including transplant KDOQI 6.1; KDIGO transplant 1.1
At least 6–12 months before dialysis would be needed Referral for transplant evaluation, so living donors can be tested KDIGO transplant 1.1.1
2-year kidney failure risk (KFRE) over 10 % Join a multidisciplinary kidney care team KDIGO 2024 PP 2.2.2
eGFR 15–20, or 2-year KFRE over 40 % Choose a treatment; plan a dialysis access or a transplant before dialysis KDIGO 2024 PP 2.2.3, 5.4.3; KDOQI 6.6
At least 2 weeks before PD starts PD catheter placed KDOQI 6.8
Usually eGFR 5–10, when symptoms appear Dialysis starts because of symptoms or problems, not one number KDIGO 2024 PP 5.4.1–5.4.2
Stage 4, if you have Medicare Up to 6 kidney disease education sessions; you pay 20 % after the Part B deductible; your doctor must refer you Medicare

The options side by side

Time it takes Diet and fluid Travel and work What you need at home
In-center hemodialysis Usually 3 sessions a week, about 4 hours each, plus travel, at set times The most limits on fluid, potassium, phosphorus and sodium Book a unit at your destination weeks ahead; a fixed schedule makes work harder Nothing; no care partner needed
Home hemodialysis Standard, short daily (5–7 days a week) or overnight; training takes 3–8 weeks Often more relaxed, because fluid is removed more often You choose the time, which makes work easier; you can travel with a machine or book a unit Space for a machine and supplies; usually a trained care partner
Peritoneal dialysis (PD) By hand: at least 4 exchanges a day, 30–40 minutes each (CAPD). By machine: 3–5 exchanges overnight (APD). Training takes 1–2 weeks Fluid limits are often less strict; sodium and phosphorus still limited Supplies can be shipped to where you are going; overnight PD leaves the day free Storage for boxes of fluid; a cycler for APD; no partner needed once trained
Kidney transplant Surgery, then frequent clinic visits at first; anti-rejection medicines every day for life The fewest limits Most like life before kidney failure once things settle Your medicines and a phone that is always on while you wait
Comprehensive conservative care Regular clinic visits focused on symptoms Eat for comfort and strength, with a dietitian's help; older or frail people may need more protein, not less No dialysis schedule Support from family, the kidney team and, later, palliative or hospice care

Sources for the table: NIDDK: choosing a treatment; NIDDK: hemodialysis; NIDDK: peritoneal dialysis; NKF: home hemodialysis; NIDDK: transplant; NIDDK: conservative management; NKF: travel. Protein for older or frail people: KDIGO 2024, practice point 3.3.1.5.

Infection risks differ. For hemodialysis, a fistula or graft has a lower infection risk than a catheter in a vein (KDOQI, statement 2.3). With PD, the main risk is an infection of the belly lining, peritonitis. After a transplant, anti-rejection medicines make infections more likely. See Dialysis access.

What each option means for type 1 diabetes

  • Hemodialysis: glucose often falls during a session, and most lows come in the 24 hours after it. Check before and after each one, and ask for a written insulin plan for dialysis days (JBDS–Renal Association; JBDS 2022).
  • Peritoneal dialysis: most PD fluids contain sugar, which you absorb, so insulin needs often change (DaVita). One PD fluid (icodextrin) makes some glucose meters read falsely high; use a meter your team says is safe (MHRA). Your PD plan should be built around your goals and how you feel, not only lab numbers (ISPD 2020).
  • Transplant: ask about a simultaneous pancreas-kidney (SPK) transplant. KDIGO suggests that people with type 1 diabetes be considered for one where it is available (KDIGO transplant, 8.1.1). A working pancreas transplant can bring glucose back to normal (ADA 2026 §9).
  • Conservative care: you still need insulin every day, because type 1 diabetes always needs it (ADA 2026 §9). Glucose goals may be relaxed for comfort and to avoid lows (ADA 2026 §6).

See Insulin on dialysis for more.

What to do

  • Ask your kidney team for your eGFR trend and your 2-year KFRE, so you know how much time you have.
  • If you have Medicare, ask your doctor to refer you for kidney disease education sessions.
  • Ask for a transplant referral now if your eGFR is under 30 (Transplant referral).
  • Visit a dialysis unit. Ask to talk with people who use home hemodialysis, PD and in-center hemodialysis, and with someone who has had a transplant (NIDDK).
  • Write down what matters most to you: work, travel, family time, independence, or fewer hospital trips.
  • Bring a family member or friend to the education sessions. They may become your care partner.
  • Agree a written plan with your team and review it at least once a year (KDOQI, statements 1.1–1.2).
  • Once you choose, plan your access early: a fistula can take months to be ready (Dialysis access).

Examples

A full-time worker. A 38-year-old teacher has an eGFR of 18. A transplant from a living donor before dialysis is the first goal (KDIGO transplant, 1.4), so her sister starts donor testing. In case dialysis comes first, she chooses overnight PD, so her days stay free. Her PD catheter goes in a few weeks before she needs it.

Someone who wants others to run the machine. A 60-year-old man lives alone and does not want supplies in his small flat. In-center hemodialysis three mornings a week suits him. He asks the unit for an early slot so he can keep his part-time job.

An older person with other serious illnesses. An 84-year-old woman with heart failure is tired and wants to stay at home with her family. After talking it through with her team, she chooses conservative care. Her team keeps treating her anemia, itch and poor appetite, and she makes an advance care plan (Advance care planning).

Your rights at a US dialysis unit. A US dialysis unit must tell you about every treatment, including transplant and home dialysis. It must also give you information about options it does not offer (42 CFR 494.70).

Ask your care team

  1. What is my 2-year and 5-year risk of kidney failure, and how much time do I have to decide?
  2. Which options would suit my health? Is anything ruled out for me, and why?
  3. Can I have a transplant before dialysis? Can I be referred for a pancreas-kidney transplant?
  4. Can I try home dialysis? What would I need at home, and do I need a care partner?
  5. How would each option change my insulin plan and my glucose checks?
  6. If I choose one option and it does not suit me, how do I switch?

Get help now if…

Call 911 (or your local emergency number)

Chest pain, severe breathlessness or being unable to lie flat, new confusion or a seizure, or a low blood glucose the person cannot treat themselves (give glucagon, then call). Full list: Get help now.

Call your kidney team today

New or worse swelling, much less urine, vomiting or not being able to eat, severe itch, or trouble thinking clearly. These can be signs that kidney failure needs treatment soon (KDIGO 2024, Table 41).

Sources

Not yet reviewed by a clinician. Facts and sources last checked 2026-10-06. Prices and benefit amounts as of 2026-10-06.