What is the difference between End-Stage Renal Failure (ESRF) and Chronic Kidney Disease stage 5 (CKD 5)?

Difference Between ESRF and CKD Stage 5

ESRF (End-Stage Renal Failure) is an outdated administrative term that should be avoided, while CKD Stage 5 (also called kidney failure) is the preferred clinical term defined by GFR <15 mL/min/1.73 m² or treatment with dialysis, regardless of whether the patient receives kidney replacement therapy. 1

Key Terminology Distinctions

ESRF/ESRD is an Administrative Term, Not a Clinical Definition

• The term "end-stage renal disease" (ESRD) or "end-stage renal failure" (ESRF) should be avoided because it is not well-defined or consistently used except for administrative purposes 1
• In the United States, ESRD is a federal statute term that refers to entitlement for Medicare coverage when patients receive dialysis or transplantation, rather than describing the actual medical condition itself 1
• ESRD/ESRF only applies to patients receiving treatment (dialysis or transplantation), excluding patients with the same level of kidney dysfunction who do not receive treatment by choice, lack of recognition, or unavailability 1
• The term misleadingly implies that the end of life is near and carries stigma, even though patients can survive for years with treatment 1

CKD Stage 5 is the Preferred Clinical Term

• CKD Stage 5 (kidney failure) is defined by GFR <15 mL/min/1.73 m² or treatment by dialysis, representing loss of more than 85% of kidney function 1, 2, 3
• This definition applies to all patients meeting the GFR criteria, regardless of whether they receive kidney replacement therapy 1
• The KDIGO 2020 consensus conference unanimously agreed that "kidney failure" should replace "end-stage" terminology for describing this stage of disease 1

Clinical Implications of the Distinction

Comprehensive Classification Requirements

• CKD Stage 5 requires further specification beyond just the GFR category: duration of disease, presence or absence of uremic symptoms, and treatment status (with or without kidney replacement therapy) 1
• Patients should be classified as "CKD G5" with additional descriptors such as "CKD G5D" (treated by dialysis) or "CKD G1T-G5T" (after transplantation) 1

Patients Not Receiving Treatment

• CKD Stage 5 includes patients who meet the GFR criteria but are not receiving dialysis or transplantation, whether by choice, lack of access, or because comprehensive conservative care is being provided 1
• ESRD/ESRF terminology excludes these patients entirely, creating a gap in clinical classification 1

Uremic Symptoms and Treatment Timing

• Approximately 98% of patients with kidney failure in the United States begin dialysis when their GFR is <15 mL/min/1.73 m², often accompanied by signs and symptoms of uremia 1
• The presence or absence of uremic syndrome (symptoms and signs associated with kidney failure) should be specified when classifying CKD Stage 5 1, 4

Common Pitfalls to Avoid

• Do not use ESRD, ESRF, ESKD, or ESKF terminology in clinical documentation—these terms are explicitly listed as "terms to avoid" by KDIGO 1
• Do not assume all patients with GFR <15 mL/min/1.73 m² are receiving dialysis—specify treatment status explicitly 1
• Do not rely solely on GFR for classification—include cause of kidney disease and albuminuria category (CGA classification) for complete risk stratification 3
• Recognize that the decision to initiate dialysis is subjective and varies greatly among physicians and countries, so GFR <15 mL/min/1.73 m² alone does not automatically mean dialysis is required 4