When a consultant says the kidneys have failed, most people in Ireland hear one word: dialysis. The conversation that follows is usually about which unit, which days, how far the drive is. What far fewer people are told, clearly and early, is that for some people after 70 the option with the best evidence behind it is not dialysis at all.
This is not about giving up. It is about a third pathway with a name, a care plan and a growing evidence base, and about a decision that is far more finely balanced after 70 than the default assumes.
TL;DR
- At 31 December 2025, 5,496 people in Ireland were on treatment for end-stage kidney disease: 2,849 with a working transplant, 2,296 on in-centre haemodialysis, 351 on home dialysis.
- A third option exists: conservative kidney management actively treats symptoms without ever starting dialysis. Ireland does not count how many people are on it.
- Dialysis clearly extends life in younger, fitter patients. Past roughly 75 to 80, or with significant frailty, the survival gap narrows sharply and in the frailest groups disappears.
- Quality-of-life scores converge between the pathways over time, and kidney-specific quality of life often favours conservative management.
- Revenue allows €0.24 per kilometre for dialysis travel with no cap on journeys, plus flat-rate 2025 relief of €3,614 for home dialysis electricity.
What “kidney failure” actually means after 70
Kidney function is measured as eGFR, an estimate of how much blood the kidneys filter per minute. It falls gradually with age in almost everyone, which is exactly why the number alone is a poor guide after 70. A reading that would alarm a nephrologist in a 45-year-old may represent decades of stable, unremarkable ageing in someone of 78.
What matters is the trajectory: how fast it is falling, whether protein is leaking into the urine, and whether symptoms have arrived. Kidney failure, or stage 5, is generally an eGFR below 15, and even then progression after 70 is often slow, with many people living for years at that level without ever needing replacement treatment. If you are earlier in the journey, our guide to kidney health after 50 covers prevention and screening, and the sick day rules matter enormously for protecting whatever function you still have.
Ireland’s numbers, and the one nobody collects
On World Kidney Day, 12 March 2026, the HSE’s National Renal Office published the national picture as it stood on 31 December 2025. There were 5,496 people receiving renal replacement therapy: 2,849 with a functioning transplant, 2,296 on in-centre haemodialysis and 351 on home dialysis. Professor Joe Eustace, the HSE’s Clinical Lead for the National Renal Office, described transplant, which more than half of them have, as the optimal way of treating kidney failure.
Look closely and something is missing. That list counts everyone receiving a machine or an organ. It does not count the people who considered both and chose a different path, because Ireland does not systematically record them.
The first door: in-centre haemodialysis
This is the default, and for good reason: it works, it is available nationwide, and for most people under 70 it buys years of life. It typically means three sessions a week, roughly four hours each, plus travel at both ends. For someone in rural Ireland that can be a full day, three days a week, indefinitely.
The burden is the part underplayed at the point of decision. Many people describe a recovery period after each session, sometimes several hours, sometimes most of the following day. That is the cost side of the ledger, and it deserves stating as plainly as the survival side.
The second door: home dialysis and transplant
Home dialysis, whether haemodialysis or peritoneal dialysis, changes the arithmetic considerably. In 2025 more than 115,000 dialysis treatments in Ireland took place at home, saving over 100,000 journeys and more than 190,000 hours that would otherwise have been spent in hospital. Yet only 351 of the 2,647 people on dialysis are doing it at home, around 13 per cent, well short of the 20 per cent international benchmark.
Transplant is the other route, and age is not the barrier many assume. There is no fixed upper age cut-off in Ireland; suitability turns on cardiovascular fitness, other conditions and frailty rather than the year on the birth certificate. In 2025, 136 kidney transplants were performed, 29 from living donors, out of 202 organ transplants nationally, down from 263 the year before. At the end of 2024 around 540 people were waiting for a kidney, roughly 80 per cent of the whole transplant list and, by the Irish Kidney Association’s estimate, about one in five of everyone on dialysis.
Since 17 June 2025, when Part 2 of the Human Tissue Act 2024 commenced, Ireland has operated a soft opt-out system: consent for donation after death is presumed unless you have registered on the national opt-out register, and families are always consulted. The same Act made altruistic donation to a stranger lawful. The National Kidney Transplant Service is at Beaumont Hospital, 01 809 3119.
The third door: conservative kidney management
Conservative kidney management is not palliative care and it is not doing nothing. It is an active treatment plan that manages anaemia, fluid, blood pressure, bone chemistry, itch, nausea and fatigue, and aims to preserve whatever kidney function remains, with the specific decision not to start dialysis. Care continues, appointments continue, medication continues. What stops is the machine.
The evidence is more nuanced than the word “conservative” suggests. A long-running UK cohort found median survival from entry into stage 5 of 38.2 months on the dialysis pathway against 23.1 months with conservative management, a real difference. But in cohorts aged over 75 the gap narrowed to roughly 36 months against 25, and among those with severe additional illness it shrank to about 26 against 21 and ceased to be statistically significant. In the frailest series studied, no survival advantage from dialysis was found at all.
A 2026 single-centre Dutch study of 522 people aged 65 and over went further, separating those who chose conservative management while still being considered suitable for dialysis from those who were not. Median survival from the moment of decision was 53 months for dialysis, 32 months for conservative management among those suitable for dialysis, and 18 months for those who were not. That middle figure is considerably longer than earlier research suggested, and it matters, because it describes precisely the person facing a genuine choice.
What the trade-off looks like day to day
Survival is only one axis. Reviews consistently find that overall quality-of-life trajectories converge between the two pathways over 12 to 36 months, and that kidney-disease-specific quality of life often favours conservative management, reflecting lower treatment burden and greater autonomy. Two of three studies of hospital use found more admissions among people on dialysis, and those managed conservatively were around four and a half times more likely to die at home rather than in hospital.
The most sobering data concerns those already frail. A large American study of nursing home residents who started dialysis found mortality of 24 per cent at three months, 41 per cent at six and 58 per cent at twelve, alongside marked and sustained loss of the ability to manage daily tasks. Living longer and living better are not the same thing, and in this group dialysis often delivered neither.
Every serious analysis lands in the same place: frailty, the number of other conditions and functional trajectory predict outcomes far more powerfully than which pathway is chosen, which is why a formal frailty assessment belongs in this conversation and often is not in it. Our guide to understanding frailty after 50 is worth reading beforehand. One further signal: the rate at which eGFR is falling independently predicts survival on conservative management, but not on dialysis, so the slope of your own readings over two years tells you more than any single result.
What to ask, and when
Bring these to the clinic, ideally with someone else in the room taking notes:
- Is conservative kidney management an option in my case, and if not, why not?
- Given my age, frailty and other conditions, what is the realistic survival difference between the options for someone like me?
- How many hours a week, including travel and recovery, would dialysis take from me?
- Am I a candidate for home dialysis or for transplant assessment, and who decides?
- If I start dialysis and find it is not for me, can I stop?
That last question has a clear answer. In the Dutch cohort, 13 per cent of those who initially chose dialysis later moved to conservative management, while only 1 per cent moved the other way. The decision is reversible, and knowing that makes it easier to make.
The money nobody claims
Ireland’s supports here are useful and badly publicised. Revenue allows kidney patients relief beyond the ordinary health expense categories. If you travel by private car for hospital dialysis you can claim €0.24 per kilometre, or €0.39 per mile, with no limit on journeys. Home dialysis patients can claim flat-rate relief which for 2025 stands at €3,614 for electricity, €2,410 for laundry and protective clothing and €390 for telephone. For CAPD the 2025 electricity figure is €2,854.
The catch is real: relief comes at the standard 20 per cent rate, is claimed through your annual tax return after the year has ended, and only works if somebody in the household has paid tax. The Irish Kidney Association has argued for years that waiting twelve months for partial reimbursement of a running electricity bill is not viable for many households, and it is a fair point. The HSE separately operates a Living Donor Reimbursement Policy.
Deciding while you can decide
A national survey published in April 2025 by RCSI, funded by the Irish Kidney Association with the HSE’s National Renal Office, asked over 1,000 people living with kidney failure in Ireland about their care. Satisfaction was high: 80 per cent on dialysis and 79 per cent of transplant recipients said their treatment was “the best it can be”. The gaps named were renal dietetics, psychological support and financial support for home dialysis.
Which leaves the decision itself. Make it early, make it explicit, and write it down. An advance healthcare directive lets you record what you would and would not want if you could no longer say so, and conservative management sits comfortably alongside palliative care services when the time comes. At Críonna Health we keep returning to the same principle: the goal is not the longest possible life measured in months, but the life you would actually choose, described in your own words, before anyone has to guess.
Ask about the third door. It may not be right for you. But you are entitled to know it is there.
Where to get help: Irish Kidney Association Patient Support, ika.ie/patient-support. National Kidney Transplant Service, Beaumont Hospital, 01 809 3119. HSE National Renal Office, hse.ie. Health expense relief, revenue.ie. Organ donation opt-out register, Organ Donation Transplant Ireland.
This article is for general information and is not a substitute for individual medical advice. Decisions about dialysis, transplant or conservative kidney management should be made with your nephrology team, who know your full clinical picture.
📷 Photo by Vitaly Gariev on Unsplash
