What constitutes End-Stage Renal Disease (ESRD)?

Definition of End-Stage Renal Disease (ESRD)

End-Stage Renal Disease (ESRD) is defined as kidney failure with a glomerular filtration rate (GFR) less than 15 mL/min/1.73 m² or the need for kidney replacement therapy (dialysis or transplantation), which corresponds to Stage 5 Chronic Kidney Disease (CKD) in the K/DOQI classification system. 1

Clinical Definition vs. Administrative Term

• ESRD is primarily an administrative term in the United States, specified in federal statute as "a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life" 2
• The term is used for Medicare entitlement purposes rather than as a precise clinical descriptor of the condition itself 2
• Kidney failure is the preferred clinical term, defined as GFR <15 ml/min per 1.73 m² or treatment by dialysis 2
• Approximately 98% of patients with kidney failure in the United States begin dialysis when their GFR is < 15 mL/min/1.73 m² 1

Recommended Terminology

• The Kidney Disease: Improving Global Outcomes (KDIGO) consensus conference recommends avoiding the term "end-stage" for describing kidney disease or patients with the condition 2
• The rationale is that the term is not well defined or consistently used outside of administrative purposes and carries negative connotations 2
• The term "kidney failure" is recommended instead, with further specification based on duration, symptoms, and treatment 2
• For epidemiologic studies, the term "kidney failure with replacement therapy" (KFRT) should be used to describe CKD G5 treated by dialysis or CKD G1-G5 after transplantation 2

Clinical Characteristics of Kidney Failure

• Kidney failure may present with symptoms and signs collectively termed uremia or the uremic syndrome 2
• Symptoms may be mild and nonspecific, and there are no generally accepted standardized instruments to assess them 2
• Kidney failure requires specification of:
  • Duration (acute: ≤3 months; chronic: >3 months) 2
  • Presence or absence of symptoms and signs 2
  • Treatment modality (dialysis, transplantation, or conservative management) 2

Treatment Options

• Kidney replacement therapy (KRT) includes both dialysis and transplantation 2
• Dialysis modalities include hemodialysis and peritoneal dialysis, with specific terminology for duration and frequency 2
• Kidney transplantation is specified as CKD G1T-G5T (CKD G1-G5 after transplantation) 2
• Conservative therapy without dialysis or transplantation may be appropriate for some patients 1

Clinical Implications

• When patients reach CKD stage 5 (eGFR < 15 mL/min/1.73 m²), nephrologists should evaluate the benefits, risks, and disadvantages of beginning kidney replacement therapy 1
• Patients who reach CKD stage 4 (eGFR < 30 mL/min/1.73 m²) should receive timely education about kidney failure and treatment options 1
• For patients with a baseline eGFR of 35 mL/min/1.73 m², the 10-year risk of ESRD is 83% for an eGFR decline of 40% 1

Terms to Avoid

• "End-stage renal disease (ESRD)" except for administrative purposes 2
• "Renal failure," "chronic renal failure," "renal disease," and "nephropathy" 2
• "Renal/kidney impairment," "insufficiency," "dysfunction," and "azotemia" 2
• "Irreversible kidney failure" 2
• "Renal replacement therapy (RRT)" (use "kidney replacement therapy" instead) 2

Important Clinical Considerations

• GFR should be estimated using validated equations or by measurement of creatinine and urea clearances, not simply by measurement of serum creatinine and urea nitrogen 1
• Avoid relying solely on serum creatinine measurements to estimate GFR, as this can lead to inaccurate assessment of kidney function 1
• Be aware that HbA1c accuracy may be affected at eGFR < 30 mL/min/1.73 m², particularly in patients receiving dialysis and erythropoietin-stimulating agents 1