an important consideration.24 The long-term effect of modality choice is unclear. Although some researchers compare the outcomes of PD and HD in registry studies,23,25 they cannot consider differences in patients’ health at the time of treatment initiation, which likely affects treatment outcomes. Additionally, because HD is more resourceintensive, PD may be more feasible than HD in lower income countries.26 Kidney transplantation is the other (perhaps preferable) KRT method whereby a recipient receives a kidney from either a live or a deceased donor. Prospective recipients are examined, and if eligible for surgery, are placed on a waiting list until an appropriate match is available. Following the transplantation surgery, patients are monitored and given anti-rejection medications or immunosuppressive agents to prevent their bodies from attacking their new kidneys. There are a number of barriers to kidney transplantation, especially a patient’s socio-economic status.27 Kidney transplantation also is highly resourceintensive, and many low and lower-middle income countries lack the human and financial resources to perform the surgery. Additionally, cultural, legal, and political barriers may impede organ donation, thereby limiting the benefit of this treatment option in some countries.28 The costs of KRT are exceedingly high and consume a significant proportion of health care budgets in developed countries. Many developed countries spend 2–3% of their health care budgets on treatment for patients with ESKD, even though these patients comprise just 0.1–0.2% of the total population. KRT remains unattainable in most developing countries due to associated costs.3,5,10 It is estimated that more than 80% of all patients receiving treatment for ESKD reside in developed countries, which have relatively larger elderly populations and universal access to care for kidney disease. Developing countries have similar CKD incidence rates, but much lower prevalence of treated kidney failure than the developed world.7,8 Many estimates place the reported prevalence of treated ESKD in sub-Saharan Africa at less than one-tenth that of the United States. Although comprehensive data are not readily available from less developed countries, it appears that proportionately fewer patients in these regions receive treatment for ESKD.7,8 1.3.2 Conservative care Conservative care refers to the management of health conditions using non-invasive practices, whereby the intent is to maintain health as much as possible and mitigate adverse events. The concept of conservative care in ESKD is relatively new.29 In this context, conservative care is the management of ESKD without the use of KRT. In 2013, the definition of conservative care for ESKD management was established as “planned holistic patient-centered care for patients with G5 CKD,”29 which can include a number of components such as interventions to delay worsening renal function or minimize adverse events; shared decision-making; active symptom management; communication plans; Many developed countries spend 2–3% of their health care budgets on treatment for patients with ESKD, even though these patients comprise just 0.1–0.2% of the total population. ISN Global Kidney Health Atlas | 2019 Introduction | 23 psychological, social, and family support; and cultural or spiritual care.29 Patients who receive conservative care are likely to experience symptoms, and therefore should supplement treatment with appropriate palliative care.30,31 Deciding whether to manage ESKD through traditional methods (dialysis or kidney transplantation) or conservative care requires careful consideration of each patient’s health status and wishes. The initiation of dialysis in the elderly may actually result in increased frailty, loss of independence, and decreased cognitive functioning.32 The burden of dialysis is substantial, and many patients prefer conservative care due to the impact of dialysis on quality of life.33 Furthermore, dialysis, when compared to conservative care, does not appear to prolong life or improve physical and mental health outcomes among patients over 80 years of age or those with multiple other health problems.34 The benefits of conservative care on patient quality of life, combined with a lack of evidence that dialysis leads to better outcomes in some settings and lower costs of conservative care35 suggest that conservative care may be a more appropriate option for some patients with ESKD. Conservative care may be optimal in resourcelimited countries where dialysis is not available. While not a deliberate action intended to limit access to KRT, KDIGO refers to this as “choicerestricted conservative care.”29 Efforts to increase international awareness and standardization of conservative care, particularly in this setting, is important to optimize care for people with ESKD, and importantly, improve their quality of life. 1.3.3 Essential medications in ESKD care The kidneys perform a number of important life functions. For example, they produce vitamin D, control blood pressure, and promote red blood cell production. As a result, people with ESKD take many medications, typically 10–12 a day,36 to replace these functions. These often include phosphate binders, vitamin D preparations, calcimimetics, antihypertensives, antidiabetics, erythropoiesis-stimulating agents, and