Management of CKD Stage V
For patients with CKD stage V (eGFR <15 ml/min/1.73m²), continue nephroprotective medications including SGLT2 inhibitors and RAS inhibitors until dialysis is initiated, prepare for kidney replacement therapy through shared decision-making, and consider conservative kidney management for elderly patients with high comorbidity burden.
Nephroprotective Medication Management
Continue SGLT2 Inhibitors
- Once initiated, continue SGLT2 inhibitors even when eGFR falls below 20 ml/min/1.73m² until kidney replacement therapy (KRT) is started 1
- Temporarily withhold during prolonged fasting, surgery, or critical illness due to ketosis risk 1
- The reversible eGFR decrease upon initiation is not an indication to stop therapy 1
RAS Inhibitor Management
- Continue ACE inhibitors or ARBs even when eGFR falls below 30 ml/min/1.73m² 1
- Consider dose reduction or discontinuation only in specific circumstances:
- Symptomatic hypotension unresponsive to management
- Uncontrolled hyperkalemia despite medical treatment
- To reduce uremic symptoms while treating kidney failure (eGFR <15) 1
- Manage hyperkalemia with potassium-lowering measures rather than stopping RAS inhibition when possible 1
Nonsteroidal Mineralocorticoid Receptor Antagonists
- For patients with type 2 diabetes, eGFR >25 ml/min/1.73m², normal potassium, and persistent albuminuria despite maximum RAS inhibition, consider adding nonsteroidal MRA 1
Kidney Replacement Therapy Planning
Treatment Modality Selection
Prioritize pre-emptive kidney transplantation when feasible, as it offers the best patient outcomes 2, 3
For patients requiring dialysis:
- Base dialysis initiation on clinical symptoms and shared decision-making, not laboratory values alone 3
- Most patients receive hemodialysis—preserve peripheral veins starting at CKD stage III 2
- Hemodialysis patients benefit from blood pressure control and volume management through adequate dialysis and sodium restriction (2g/day) 1, 2
Conservative Kidney Management
For elderly patients (>75 years) with high comorbidity burden, particularly ischemic heart disease, conservative management is a reasonable alternative to dialysis 4
Key considerations:
- The survival advantage of dialysis is substantially reduced or lost in patients over 75 with high comorbidity scores 4
- Conservative management emphasizes symptom control without kidney replacement therapy 3
- This approach is particularly appropriate for patients with limited life expectancy or those wishing to avoid medical interventions 2
Symptom Management
Patients with stage 5 CKD experience considerable symptom burden comparable to advanced cancer populations 5:
Most prevalent symptoms requiring management:
- Lack of energy (76%)
- Pruritus (74%)
- Drowsiness (65%)
- Dyspnea (61%)
- Pain (53%—with disproportionately high severity; 32% report moderate/severe pain) 5
Address these symptoms proactively regardless of whether dialysis is planned.
Blood Pressure and Metabolic Management
- Target systolic blood pressure of 120 mmHg when tolerable 6
- Achieve through volume control (adequate dialysis, sodium restriction to 2g/day) 1, 6
- For diabetes requiring medication, insulin is the preferred treatment in ESRD 2
- Monitor for protein-energy wasting and malnutrition 2
Vaccination and Preventive Care
Vaccinate against:
- Seasonal influenza
- Tetanus
- Hepatitis B
- Streptococcus pneumoniae
- HPV (through age 26) 2
Routine cancer screening is discouraged for patients not receiving kidney transplantation 2
Critical Pitfalls to Avoid
- Do not prematurely discontinue SGLT2 inhibitors or RAS inhibitors when eGFR declines—these provide ongoing cardiovascular and renal protection 1
- Do not initiate dialysis based solely on eGFR thresholds—use symptom-based and patient-centered criteria 3
- Do not assume dialysis improves survival in all elderly patients—carefully assess comorbidity burden, especially cardiac disease 4
- Do not neglect vascular access preservation—avoid peripheral IV placement in potential dialysis patients starting at stage III CKD 2