These observations highlight the limitations of framing dialysis decisions as a binary choice. In advanced CKD, decision-making should instead be understood as a shared, structured, multidisciplinary, and dynamic process, centered on patient values rather than isolated interventions.7,8 This represents a fundamental shift from decision-making centered on treatments to decision-making centered on patients.

This shift is further supported by supportive care frameworks and KDIGO recommendations, which emphasize iterative discussions integrating prognosis, goals of care, and evolving clinical contexts.9,10 Within this context, the concept of adequation of therapeutic effort provides a practical framework to operationalize shared decision-making (SDM).8,11 SDM supports an adequation of therapeutic effort that patients and their families can understand and accept, based on a clear understanding of the patient's clinical situation. Rather than focusing on isolated interventions, this approach emphasizes jointly defining proportional goals of care aligned with prognosis, functional status, and patient values based on a multidisciplinary approach.8,12 While territorial frameworks in other areas of chronic care emphasize predefined levels of therapeutic intervention rather than crisis-driven decisions, comparable structured approaches remain largely absent in nephrology, contributing to variability in practice and reinforcing the need for dialysis-specific models aligned with SDM.7,13 These frameworks conceptualize therapeutic intensity as a dynamic construct that can be adapted over time, ranging from life-sustaining to comfort-focused care. Applied to dialysis, this approach allows initiation, continuation, adaptation, or withdrawal of treatment to be explicitly aligned with prognosis, functional status, reversibility of complications, and, critically, patient values. Establishing levels of therapeutic intervention provides a common language for patients, families, and professionals, facilitates continuity across care settings, and helps avoid disproportionate or non-beneficial interventions. Recent evidence reinforces the need to reconsider how dialysis decisions are made in patients with advanced CKD, particularly among older and frail individuals.14,15 In routine clinical practice, dialysis initiation often remains the default pathway despite limited life expectancy, high comorbidity, or functional impairment, overlooking the heterogeneity of clinical trajectories and the impact of dialysis on daily life, symptom burden, and functional independence.16 Many patients report that dialysis discussions focus primarily on technical aspects and survival, with limited attention to individual goals and values, resulting in initiation or continuation of treatment without a clear understanding of its impact on QoL, autonomy, or the balance between benefit and burden.17 This mismatch is particularly evident in situations of prognostic uncertainty, where the expected survival benefit of dialysis is modest, yet treatment burden remains high. A more appropriate approach acknowledges that decision-making in advanced CKD is dynamic and evolves over time, considering the advanced illness progression and person-centred palliative care needs at the end of life.18 Rather than framing dialysis as a single, irreversible choice, care should allow for graduated levels of intervention, time-limited therapeutic trials, and explicit multidimensional reassessment of health status and needs following intercurrent events.12

The LTI-Dialysis (level of therapeutic intervention in KRT) framework applies the principles of therapeutic proportionality and SDM to dialysis care, allowing the intensity, goals, and limits of KRT to be defined (Fig. 1). In doing so, it moves beyond the binary question of dialysis yes or no, providing a structured way to define therapeutic goals and limits in line with approaches established in other advanced illness trajectories.7 In other advanced illness trajectories, particularly oncology, structured approaches already align treatment intensity with prognosis and goals of care. In our region, this concept has been extended to multimorbid non-oncological patients through territorial protocols of therapeutic intensity adequation,13 supported by tools such as NECPAL, which facilitate the early identification of patients with advanced chronic conditions and palliative care needs.19–22 Within this context, the diagnostic and therapeutic assignment model (MADiT) was introduced as a practical tool to support clinical decision-making once a level of therapeutic intervention has been defined, providing operational guidance when uncertainty arises regarding how intensively to act within an agreed level of care.23 Despite the availability of such approaches in other fields, nephrology has largely lacked a dialysis-specific framework to define levels of therapeutic intervention. Building on evidence from person-centred care and SDM in kidney disease.8,11,16,24,25

Fig. 1.

The LTI-Dialysis framework: levels of therapeutic intervention in kidney replacement therapy. LTI-Dialysis framework illustrating four levels of therapeutic intervention in kidney replacement therapy (KRT): full dialysis for survival (LTI-D 1), full dialysis with explicit limits (LTI-D 2), adapted or palliative dialysis with three sublevels (LTI-D 3A–3C), and withdrawal of dialysis with conservative management (LTI-D 4). The lower panel depicts practical applications shown in the figure, including proportional supportive therapies, alignment of treatment intensity with patient goals and clinical trajectory, and guided transitions from peritoneal dialysis (PD) to hemodialysis (HD). Abbreviations: LTI, level of therapeutic intervention; HD, hemodialysis; PD, peritoneal dialysis; ICU, intensive care unit; CPR, cardiopulmonary resuscitation.

We propose the LTI-Dialysis framework as a dialysis-specific adaptation designed to define therapeutic goals and limits, while allowing proportional clinical action within each level.

In patients treated with PD, the LTI-Dialysis framework is particularly useful when considering transition to in-center HD. Technique failure, peritonitis, or acute clinical deterioration often prompt implicit escalation to HD. Applying LTI-Dialysis reframes this decision as a goal-oriented and proportional choice, explicitly aligned with the patient's level of therapeutic intervention. Transitions from PD to HD are generally appropriate in LTI-D 1 and LTI-D 2. They may be selectively considered in LTI-D 3A as part of a conditional trial. In contrast, such transitions are usually inconsistent with goals of care in LTI-D 3B, LTI-D 3C, or LTI-D 4.

A clinical scenario further illustrates how LTI-Dialysis levels may evolve along a patient's trajectory.

A patient receiving maintenance HD with multiple comorbidities was initially managed under LTI-D 1, with no limitations to ICU support. The patient was later admitted with a catheter-related bloodstream infection complicated by infective endocarditis and required prolonged ICU care, initially receiving continuous kidney replacement therapy (CKRT). After stabilization and transition back to intermittent HD, the patient remained profoundly frail with severe cardiac dysfunction and recurrent intradialytic hypotension, and the clinical course continued to deteriorate despite transfer to a rehabilitation facility. Following shared decision-making with the patient and family, the level of therapeutic intervention was revised toward a symptom-centered approach consistent with LTI-D 3 palliative dialysis. This example illustrates how dialysis intensity and therapeutic goals may be reassessed as the patient's clinical trajectory evolves.

The clinical usefulness of the LTI-Dialysis framework ultimately depends on its implementation in routine care. Crucially, defining the LTI-Dialysis level must be grounded in patients’ values, preferences, beliefs, and life priorities.7

Implementation of the LTI-Dialysis framework requires a structured and multidisciplinary approach. In routine practice, definition of the LTI-D level should emerge from shared decision-making involving the nephrology team, dialysis nurses, geriatricians when available, the patient, and family members, with integration of palliative care specialists when appropriate (Table 1). Dialysis nurses play a particularly important role, as they are often the first to identify changes in functional status, treatment tolerance, symptom burden, or patient priorities during routine dialysis care. Rather than representing a one-time decision, the assigned level of therapeutic intervention should be documented within the advance care planning process and revisited over time. Reassessment is particularly important after major clinical events such as hospitalizations, functional decline, dialysis intolerance, or modality failure. In this way, LTI-Dialysis becomes a dynamic tool that supports proportional adjustments in treatment intensity while maintaining alignment with patient values and goals of care.

When patients lack decision-making capacity or do not have advance directives, family members and legally designated surrogates play a central role in reconstructing these values and guiding decisions. Periodic reassessment is essential, particularly following hospitalizations, functional decline, dialysis intolerance, modality failure, or acute potentially irreversible events. By converting patient values into actionable clinical guidance, LTI-Dialysis helps reduce decisional regret and align care with patient priorities.24,26 Without such structured approaches, SDM risks remaining an aspirational concept rather than a reproducible clinical practice.

In advanced CKD, moving beyond a binary approach to dialysis decision-making is essential, and the LTI-Dialysis framework offers a structured and patient-centered way to align dialysis intensity with clinical trajectories and patient values.