Introduction <p>This narrative explored the challenges in managing a patient with end stage kidney disease. People with end stage renal failure experience variety of physical symptoms as well as psychological effect</p> Case <p>The case explored the history of an 83 year old gentleman with end stage kidney disease who initially chose to not pursue dialysis. However, due to unforeseen circumstances he changed his standpoint on dialysis. His main uraemic symptoms were pruritus and restless leg symptoms.</p> Discussion <p>This narrative allowed the exploration of important themes such as advanced care planning, management of complex symptoms in end stage kidney disease. The narrative also discusses the management of end stage kidney disease in elderly patients and the factors used to aid the clinician in deciding whether a patient is suitable for renal replacement therapy. Furthermore, the narrative explores the evidence of using dialysis to reverse contrast nephropathy. whilst also exploring the renal supportive care model, which is a new frontier in medicine which integrates renal and palliative care.</p> Conclusion <p>The case described the complexities in managing a patient with end stage kidney disease. The case also revealed the importance of having an established and integrated renal supportive care service.</p>