What is the management approach for patients with Chronic Kidney Disease (CKD) stage 5 or End-Stage Renal Failure (ESRF)?

CKD Stage 5 and ESRF: Terminology and Management

CKD Stage 5 and End-Stage Renal Failure (ESRF/ESRD) are equivalent terms referring to kidney failure with GFR <15 mL/min/1.73 m², requiring renal replacement therapy or conservative management. 1, 2

Definition and Equivalence

• CKD Stage 5 is defined by GFR <15 mL/min/1.73 m², representing loss of more than 85% of kidney function according to KDIGO guidelines 2
• This stage is synonymous with "kidney failure" and "end-stage renal disease (ESRD)" in clinical practice 1, 3
• The terminology differs primarily by regional preference, but the clinical entity and management approach remain identical 4, 3

Management Framework

Timely Nephrology Referral and Planning

• All patients with CKD Stage 4 (GFR <30 mL/min/1.73 m²) should be referred to nephrology for RRT planning when the risk of kidney failure within 1 year reaches 10-20% or higher 1
• Referral must occur at least 1 year before anticipated RRT initiation to avoid "late referral" complications 1
• Early referral (before reaching Stage 5) improves outcomes, with patients known to nephrology before CKD 5 surviving significantly longer (median 32 vs 15 months) 5

Multidisciplinary Team Management

Patients with progressive CKD Stage 5 require multidisciplinary care including: 1

• Dietary counseling for protein restriction and electrolyte management 1, 6
• Education about all RRT modalities (hemodialysis, peritoneal dialysis, transplantation) 1, 7
• Vascular access surgery planning 1, 3
• Psychological and social support services 1
• Conservative management counseling as a valid option 1

Timing of Dialysis Initiation

Dialysis should be initiated based on clinical symptoms, not GFR alone, typically when one or more of the following are present: 1, 7

• Uremic symptoms: serositis (pericarditis, pleuritis), pruritus, uremic encephalopathy with cognitive impairment 1, 7
• Refractory fluid overload or uncontrolled hypertension despite diuretics 1, 7
• Progressive malnutrition despite dietary intervention 1, 7
• Severe electrolyte abnormalities (hyperkalemia, metabolic acidosis) 1, 7
• Uremic bleeding from platelet dysfunction 7

These symptoms typically occur when GFR is between 5-10 mL/min/1.73 m², but the decision must be symptom-driven rather than GFR-driven 1

Transplantation Considerations

• Living donor preemptive renal transplantation should be considered when GFR <20 mL/min/1.73 m² with evidence of progressive, irreversible CKD over 6-12 months 1
• Transplantation is the treatment of choice for eligible ESRD patients and offers superior survival compared to dialysis 3

Conservative Management Option

Conservative management without RRT is a valid option and must be discussed with all CKD Stage 5 patients 1

• This approach is particularly appropriate for patients with multiple comorbidities, advanced age, or frailty 7
• Median survival for conservatively managed CKD 5 patients is approximately 21 months, with better outcomes (32 months) in those with early nephrology involvement 5
• Serum albumin >35 g/L predicts better survival in conservatively managed patients 5
• Comprehensive palliative care and hospice referral should be provided for patients choosing conservative management 1, 3

Medical Management in CKD Stage 5

Blood Pressure Control

• Target BP <130/80 mmHg using ACE inhibitors or ARBs as first-line therapy 8, 6
• Monitor serum creatinine and potassium within 5-7 days after initiating or adjusting doses 8
• Discontinue or reduce dose if creatinine rises >30% from baseline or potassium >5.5 mEq/L 8
• Loop diuretics (not thiazides) are required for volume control when GFR <30 mL/min 8, 6

Complications Management

Address the following complications systematically: 6, 3

• Hyperkalemia: Avoid potassium-sparing diuretics; consider newer potassium binders (patiromer, sodium zirconium cyclosilicate) to enable continued RAS inhibitor use 8
• Metabolic acidosis: Correct with sodium bicarbonate supplementation 6, 3
• Anemia: Administer erythropoietin-stimulating agents 6, 3
• Mineral bone disorder: Provide vitamin D derivatives and phosphate binders 6, 3
• Protein-calorie malnutrition: Implement low-protein diet (0.6-0.8 g/kg/day) with nutritional monitoring 6, 3

Critical Pitfalls to Avoid

• Never rely solely on serum creatinine—always calculate eGFR using validated equations (MDRD or CKD-EPI) that account for age, sex, race, and body size 1, 2, 8
• Do not initiate dialysis based on GFR threshold alone without clinical symptoms, as early dialysis initiation does not improve outcomes 1
• Avoid NSAIDs entirely in CKD Stage 5, as they worsen renal function and increase hyperkalemia risk 8, 6
• Do not discontinue ACE inhibitors/ARBs prematurely when creatinine rises <30%, as initial rises are expected and do not indicate harm 8
• Never use thiazide diuretics when GFR <30 mL/min, as they are ineffective at this level of renal function 8

Prognosis

• CKD Stage 5 patients have extremely high cardiovascular mortality risk, with 3-year and 5-year survival rates on dialysis of only 55% and 40% respectively 2
• Approximately 35-40% of CKD Stage 5 patients can maintain stable kidney function with conservative treatment for over 2 years, delaying dialysis initiation 9
• Independent factors predicting non-progression include higher eGFR at referral and use of ACE inhibitors/ARBs 9