What are the recommended steps for initiating predialysis care in an adult with chronic kidney disease stage 5 (eGFR < 15 mL/min/1.73 m²) or rapidly declining renal function?

Predialysis Care in Advanced CKD

For adults with CKD stage 5 (eGFR <15 mL/min/1.73 m²), initiate comprehensive predialysis planning immediately, focusing on dialysis access preparation, patient education about treatment modalities, and continuation of nephroprotective medications while targeting specific clinical indications rather than arbitrary eGFR thresholds for dialysis initiation 1, 2.

When to Begin Predialysis Planning

Start planning for dialysis access and preemptive kidney transplantation when eGFR falls to 15-20 mL/min/1.73 m² or when the 2-year risk of kidney replacement therapy exceeds 40% 2. This timing allows adequate preparation without premature intervention.

Continue Disease-Modifying Therapies

A critical and often overlooked aspect: do not automatically discontinue nephroprotective medications at advanced CKD stages 1:

• Continue SGLT2 inhibitors even when eGFR falls below 20 mL/min/1.73 m² if already initiated and tolerated, unless dialysis begins 1
• Continue ACE inhibitors or ARBs even when eGFR drops below 30 mL/min/1.73 m² 1
• Only consider reducing or stopping RASi if: symptomatic hypotension occurs, uncontrolled hyperkalemia persists despite treatment, or to reduce uremic symptoms in kidney failure (eGFR <15) 1

This represents a paradigm shift from older practices of discontinuing these medications prematurely.

Dialysis Initiation Criteria

Base the decision to start dialysis on clinical symptoms and signs, NOT on eGFR alone 2, 3. The IDEAL trial definitively showed that early dialysis initiation (eGFR >10 mL/min/1.73 m²) provides no mortality or morbidity benefit 3.

Specific Indications for Dialysis Initiation

Initiate dialysis when one or more of the following are present 2:

• Uremic symptoms: pericarditis, encephalopathy, intractable nausea/vomiting, bleeding diathesis
• Fluid overload refractory to diuretic therapy
• Hyperkalemia unresponsive to medical management
• Metabolic acidosis resistant to treatment
• Malnutrition refractory to nutritional intervention
• In children specifically: poor growth despite optimized nutrition, growth hormone, and medical management 2

These indications typically manifest when eGFR is between 5-10 mL/min/1.73 m², but the presence of symptoms, not the number, drives the decision 2.

Patient Education and Modality Selection

Provide structured education about all kidney replacement options when eGFR reaches 15-20 mL/min/1.73 m² 2, 4:

• Preemptive kidney transplantation (living or deceased donor)
• Home hemodialysis
• Peritoneal dialysis
• In-center hemodialysis
• Conservative kidney management (particularly for elderly patients with significant comorbidities)

Tele-education has proven noninferior to face-to-face education for increasing home dialysis selection and patient confidence 2.

Prioritize Preemptive Transplantation

Preemptive kidney transplantation offers the best outcomes and should be actively pursued 2, 5. Begin evaluation and living donor assessment when eGFR is 15-20 mL/min/1.73 m². For children, preemptive transplantation is the treatment of choice, typically performed when eGFR is 5-15 mL/min/1.73 m² depending on age, size, and progression rate 2.

Blood Pressure Management

Target systolic BP of 120 mm Hg when tolerable using standardized measurement techniques 1, 6. Continue aggressive BP control even at advanced CKD stages to reduce cardiovascular events.

Common Pitfalls to Avoid

1. Do not stop SGLT2 inhibitors or RASi prematurely based solely on declining eGFR 1
2. Do not initiate dialysis based on eGFR alone in asymptomatic patients—this leads to unnecessary early dialysis without benefit 3
3. Do not delay nephrology referral—late referral (within months of dialysis need) increases initial morbidity and mortality 7, 8
4. Do not use creatinine-based eGFR as the sole decision tool at very low GFR levels, as accuracy is poor 3

Special Considerations for Older Adults

For elderly patients with substantial comorbidities and frailty, carefully weigh dialysis initiation against conservative kidney management 3, 5. Dialysis may worsen quality of life and outcomes in this population. This requires shared decision-making emphasizing symptom management and patient preferences.

Monitoring During Predialysis Period

• Check BP, creatinine, and potassium within 2-4 weeks after initiating or increasing nephroprotective medications 1
• Manage hyperkalemia aggressively with dietary modification and potassium binders rather than stopping RASi 1
• Monitor for uremic symptoms systematically at each visit
• Assess nutritional status regularly, as malnutrition is both a complication and an indication for dialysis