What are the treatment options for a patient with Chronic Kidney Disease (CKD) stage 5?

Treatment Options for CKD Stage 5

Patients with CKD Stage 5 (GFR <15 mL/min/1.73 m²) require renal replacement therapy (RRT) or conservative management, with the specific approach determined by clinical symptoms rather than GFR alone, and all patients must receive comprehensive education about every treatment option including kidney transplantation, peritoneal dialysis, hemodialysis, and conservative care. 1, 2

Immediate Assessment and Referral

• All CKD Stage 5 patients must be under nephrology care within a multidisciplinary team including nephrologist, nephrology nurse, dietitian, and social worker 3, 4
• If not already referred, immediate nephrology consultation is mandatory as these patients should have been referred at Stage 4 (GFR <30 mL/min/1.73 m²) at least 1 year before anticipated RRT need 1, 5
• Evaluate for absolute indications requiring urgent RRT initiation: uremic symptoms (pericarditis, encephalopathy, bleeding), diuretic-refractory pulmonary edema, severe hyperkalemia unresponsive to medical therapy, or severe metabolic acidosis 1, 2

Treatment Modality Selection Algorithm

Option 1: Preemptive Kidney Transplantation (Preferred When Feasible)

This is the optimal choice for appropriate candidates and should be pursued aggressively. 5

• Eligibility criteria: No urgent uremic symptoms, availability of living donor or very short deceased donor wait time, patient at early Stage 5 or late Stage 4 5
• Advantages: Avoids dialysis-associated cardiovascular stress, preserves residual kidney function, superior quality of life 5
• Timing: Begin transplant evaluation when GFR approaches 20 mL/min/1.73 m², not waiting until <15 mL/min/1.73 m² 5
• Cardiac screening required: Obtain resting echocardiogram and 12-lead ECG; patients meeting low-risk criteria (age <60, no diabetes/cerebrovascular/peripheral artery disease, no silent MI on ECG) do not require stress testing 5
• Critical caveat: Still prepare backup dialysis access (arteriovenous fistula evaluation or peritoneal dialysis catheter readiness) in case transplantation is delayed 5

Option 2: Hemodialysis

Initiate when clinical symptoms develop, not based on GFR threshold alone. 1

• Vascular access planning: Must begin immediately if not already done—arteriovenous fistula (AVF) is preferred and requires 6-8 months for maturation 6
• AVF placement criteria: Blood flow >600 mL/min, diameter >0.6 cm, depth approximately 0.6 cm from skin surface (Rule of 6s) 6
• Alternative access: Arteriovenous graft (AVG) if veins inadequate for fistula—requires 3-6 weeks maturation 6
• Temporary access: Tunneled cuffed catheter in internal jugular vein (never subclavian—causes central vein stenosis and destroys ipsilateral arm for future access) 6
• Absolute contraindication: Never use peripherally inserted central catheters (PICCs) in CKD patients—they cause 11-85% upper-extremity thrombosis and destroy potential fistula sites 6

Option 3: Peritoneal Dialysis

• Patient education required: Comprehensive training on technique, infection prevention, and catheter care 2, 4
• Catheter placement: Should be placed and allowed to heal before initiating dialysis 4
• Advantages: Home-based therapy, preserves residual kidney function longer, no vascular access needed 2
• Limitations: Inadequate for acute situations requiring rapid fluid/solute removal 2

Option 4: Conservative Management Without Dialysis

This is a valid and appropriate option that must be discussed with all CKD Stage 5 patients. 1

• Appropriate candidates: Patients with multiple comorbidities, advanced age, frailty, or those who decline dialysis after informed decision-making 1
• Management approach: Low-protein diet, loop diuretics for volume control, palliative care principles for symptom management 2
• Patient autonomy: This choice must be respected and supported with comprehensive symptom management 1

Medical Management During Stage 5 (All Patients)

Cardiovascular and Blood Pressure Control

• Target BP: <130/80 mmHg using ACE inhibitors or ARBs as first-line therapy 1
• Monitoring: Check serum creatinine and potassium within 5-7 days after initiating or adjusting doses 1
• Discontinuation criteria: Stop or reduce dose if creatinine rises >30% from baseline or potassium >5.5 mEq/L 1
• Diuretic selection: Use loop diuretics only (furosemide, spironolactone)—thiazides are completely ineffective when GFR <30 mL/min/1.73 m² 1, 7

Anemia Management

• ESA initiation: Start erythropoietin-stimulating agents when hemoglobin falls between 9.0-10.0 g/dL to avoid dropping below 9.0 g/dL 6
• Target hemoglobin: Maintain 11.0-12.0 g/dL in adults—never intentionally exceed 13 g/dL (increases stroke risk) 6
• Iron supplementation: Administer IV iron when transferrin saturation ≤20% and ferritin ≤100 ng/mL 6
• Monitoring frequency: Check hemoglobin at least every 3 months during maintenance ESA therapy 6
• Blood pressure monitoring: Check BP with each ESA dose due to hypertension risk 6

Mineral and Bone Disease Management

• PTH targets: For elevated PTH >300 pg/mL, use calcitriol or analogs (doxercalciferol, alfacalcidol, paricalcitol) to reverse high-turnover bone disease 6
• Adynamic bone disease: If PTH <100 pg/mL, decrease or eliminate calcium-based phosphate binders and vitamin D to allow PTH to rise 6
• Parathyroidectomy indication: Persistent PTH >800 pg/mL with hypercalcemia/hyperphosphatemia refractory to medical therapy 6
• Monitoring frequency: Measure serum calcium and phosphorus at least every 3 months; monitor PTH at least once, then every 3 months if abnormal 6

Metabolic Acidosis Correction

• Monitoring: Check serum bicarbonate at least every 3 months 6
• Treatment target: Correct chronic metabolic acidosis to serum bicarbonate ≥22 mmol/L 6

Critical Pitfalls to Avoid

• Never rely on serum creatinine alone—always calculate eGFR using validated equations (MDRD or CKD-EPI) accounting for age, sex, race, and body size 1, 2
• Do not initiate dialysis based solely on GFR threshold—early dialysis initiation without symptoms does not improve outcomes and may cause harm 1
• Absolutely avoid NSAIDs—they worsen renal function and increase hyperkalemia risk in Stage 5 CKD 1
• Do not prematurely discontinue ACE inhibitors/ARBs when creatinine rises <30%—initial rises are expected and do not indicate harm 1
• Never use subclavian vein catheters—they cause central venous stenosis and destroy the entire ipsilateral arm for future vascular access 6
• Never use PICCs in CKD patients—they cause 11-85% upper-extremity thrombosis and eliminate potential fistula sites 6
• Do not delay vascular access planning—AVF maturation requires 6-8 months, and late referral forces use of catheters with associated complications 6, 1

Prognosis and Patient Counseling

• CKD Stage 5 patients on dialysis have 3-year survival of only 55% and 5-year survival of 40%, primarily due to cardiovascular mortality 1
• Cardiovascular disease is the leading cause of death, with patients having extremely high risk for coronary artery disease, heart failure, arrhythmias, and sudden cardiac death 8
• Preemptive transplantation offers superior outcomes compared to dialysis-first approaches 5