What is the recommended management for an adult with end-stage kidney disease (eGFR <15 mL/min/1.73 m²)?

Management of End-Stage Kidney Disease (eGFR <15 mL/min/1.73 m²)

For adults with end-stage kidney disease (ESKD), initiate kidney replacement therapy (KRT) planning when eGFR falls below 15-20 mL/min/1.73 m² or when the 2-year risk of requiring KRT exceeds 40%, with the actual decision to start dialysis based on clinical symptoms, quality of life, and patient preferences rather than eGFR alone 1.

Timing of Dialysis Initiation

The decision to start dialysis should not be based solely on reaching a specific eGFR threshold. Instead, initiate dialysis when one or more of the following clinical situations develop 1:

• Uremic symptoms: Pericarditis, encephalopathy, intractable nausea/vomiting, bleeding diathesis
• Fluid overload refractory to diuretics: Causing pulmonary edema or hypertension
• **Severe metabolic acidosis unresponsive to medical management
• **Hyperkalemia resistant to conservative measures
• **Severe malnutrition despite nutritional interventions

These complications typically occur when eGFR is between 5-10 mL/min/1.73 m², but the range varies considerably 1.

Medical Management Prior to Dialysis

Disease-Modifying Medications

Even at eGFR <15 mL/min/1.73 m², continue evidence-based therapies unless specific contraindications arise:

RAS Inhibitors (ACEi/ARB): Continue these medications even when eGFR falls below 15 mL/min/1.73 m² 2. Consider dose reduction or discontinuation only for:

• Symptomatic hypotension
• Uncontrolled hyperkalemia despite medical treatment
• To reduce uremic symptoms while treating kidney failure 2

SGLT2 Inhibitors: If already initiated when eGFR was ≥20 mL/min/1.73 m², continue the medication even after eGFR drops below 20 mL/min/1.73 m², unless intolerance develops or KRT is initiated 2. Do not start new SGLT2i therapy once eGFR is <20 mL/min/1.73 m².

Critical Pitfall: Medication Management

A common error is prematurely discontinuing RAS inhibitors or SGLT2 inhibitors when eGFR declines. The KDIGO 2024 guidelines explicitly state to continue ACEi/ARB even below eGFR 30 mL/min/1.73 m² 2, and to continue SGLT2i once started even if eGFR falls below 20 mL/min/1.73 m² 2. These medications provide cardiovascular and residual kidney protection.

Treatment Modality Selection

Kidney Transplantation (Preferred)

Preemptive kidney transplantation is the optimal treatment and should be pursued when eGFR is <15-20 mL/min/1.73 m² 1. This approach:

• Avoids dialysis entirely
• Provides superior patient outcomes compared to dialysis 3, 4
• Requires early referral for evaluation and living donor identification

Dialysis Options

When transplantation is not immediately available:

Hemodialysis: Most common modality in the US

• Requires vascular access planning well in advance
• Arteriovenous fistula creation needs months to mature
• Preserve peripheral veins in patients with stage III-V CKD to maintain future access options 3

Peritoneal Dialysis: Home-based option

• No difference in long-term mortality compared to hemodialysis 4
• Allows greater patient autonomy
• Requires adequate home support and patient capability

Comprehensive Conservative Care (Non-Dialytic Management)

For patients who decline dialysis or have limited life expectancy, comprehensive conservative care is a legitimate alternative 1, 5. This approach is particularly appropriate for:

• Patients with severe comorbidities where dialysis offers no survival benefit
• Those with limited life expectancy
• Individuals who wish to avoid medical interventions 3, 5

Conservative management includes 5, 6:

• Fluid balance optimization
• Anemia treatment
• Acidosis and hyperkalemia correction
• Blood pressure management
• Calcium/phosphorus metabolism control
• Dietary sodium restriction
• Individualized symptom management
• Advance care planning and palliative care integration

Shared Decision-Making Framework

All patients with ESKD must be informed about three options: kidney transplantation, dialysis (hemodialysis or peritoneal dialysis), and comprehensive conservative care 1. The decision should incorporate:

• Patient symptoms and quality of life
• Comorbidity burden
• Life expectancy
• Patient values and preferences
• Social support systems

Monitoring and Complications Management

Continue managing ESKD complications regardless of treatment choice 3, 4:

• Hyperkalemia: Dietary restriction, potassium binders (to avoid stopping RAS inhibitors) 2
• Volume overload: Sodium restriction (<5 g/day), diuretics, adequate dialysis if applicable 7
• Metabolic acidosis: Sodium bicarbonate supplementation
• Anemia: ESA therapy and iron supplementation
• Mineral bone disorder: Phosphate binders, vitamin D analogs
• Protein-energy wasting: Nutritional monitoring and intervention 3

Vaccination Requirements

Patients with ESKD require specific vaccinations 3:

• Seasonal influenza (annual)
• Hepatitis B (essential before dialysis initiation)
• Pneumococcal vaccination
• Tetanus
• HPV (through age 26)

Blood Pressure Management

For patients on dialysis, blood pressure control improves mortality 3. Achieve this through:

• Adequate dialysis with volume removal
• Sodium restriction
• Antihypertensive medications as needed

Target BP generally <140/90 mmHg, or <130/80 mmHg for higher cardiovascular risk 7.

Diabetes Management in ESKD

Insulin is the preferred treatment for patients with ESKD and diabetes requiring medication 3. Adjust doses carefully as insulin clearance is reduced in kidney failure.