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

Management of CKD Stage 5

All patients with CKD Stage 5 (GFR <15 mL/min/1.73 m²) require immediate nephrology referral if not already under specialist care, and must choose between renal replacement therapy (RRT) or conservative management based on clinical symptoms rather than GFR alone. 1, 2

Immediate Assessment Requirements

Urgent RRT initiation is mandatory when any of the following absolute indications are present: 1, 2

• Uremic symptoms (nausea, vomiting, anorexia, altered mental status, uremic pericarditis, peripheral neuropathy)
• Diuretic-refractory pulmonary edema or refractory fluid overload
• Severe hyperkalemia unresponsive to medical therapy
• Severe metabolic acidosis unmanageable with conservative measures

Treatment Modality Selection Algorithm

First-Line Option: Preemptive Kidney Transplantation

Preemptive kidney transplantation is the optimal treatment choice and should be pursued aggressively for all appropriate candidates. 1, 2

Eligibility criteria include: 1

• No urgent uremic symptoms requiring immediate dialysis
• Availability of living donor OR very short deceased donor wait time
• Patient at early Stage 5 or late Stage 4 CKD

Advantages over dialysis-first approach: 1

• Avoids dialysis-associated cardiovascular stress
• Preserves residual kidney function
• Superior quality of life outcomes
• Better long-term survival (3-year survival 55% and 5-year survival 40% on dialysis vs. superior outcomes with preemptive transplant)

Second-Line Option: Hemodialysis

Hemodialysis should be initiated based on clinical symptoms, not GFR threshold alone. 1, 2, 3

Vascular access planning must begin immediately: 1

• Arteriovenous fistula (AVF) is the preferred access and requires 6-8 months for maturation
• Arteriovenous graft (AVG) is alternative if veins inadequate for fistula
• Central venous catheter only for urgent/unplanned dialysis (highest infection risk)

Critical timing: Vascular access planning should have occurred at Stage 4 (GFR <30 mL/min/1.73 m²), at least 1 year before anticipated RRT need. 2, 3, 4

Third-Line Option: Peritoneal Dialysis

Peritoneal dialysis is a valid home-based therapy option requiring comprehensive patient education. 1

Advantages include: 1

• Home-based therapy with greater flexibility
• Preserves residual kidney function longer than hemodialysis
• No vascular access needed
• Avoids dialysis center visits

Requirements: 1

• Patient must be capable of performing technique
• Comprehensive training on infection prevention and catheter care
• Peritoneal dialysis catheter can be placed and used within 7 days for urgent start 5

Fourth-Line Option: Conservative Management Without Dialysis

Conservative management without dialysis is a valid and appropriate option that must be discussed with all CKD Stage 5 patients. 1, 2, 3

Appropriate candidates include: 1, 2

• Patients with multiple comorbidities
• Advanced age or frailty
• Those who decline dialysis after informed decision-making
• Focus shifts to symptom management and palliative care 6

Medical Management During Stage 5

Blood Pressure and Cardiovascular Control

Target blood pressure <130/80 mmHg using ACE inhibitors or ARBs as first-line therapy. 1, 2

Monitoring protocol: 1, 2

• Check serum creatinine and potassium within 5-7 days after initiating or adjusting doses
• Discontinue or reduce dose if creatinine rises >30% from baseline
• Discontinue if potassium >5.5 mEq/L

Anemia Management

Initiate erythropoietin-stimulating agents (ESAs) when hemoglobin falls between 9.0-10.0 g/dL to prevent dropping below 9.0 g/dL. 1, 7

For adult patients with CKD on dialysis: 7

• Start treatment when hemoglobin <10 g/dL
• Target hemoglobin 11.0-12.0 g/dL in adults 1
• Recommended starting dose: 50-100 Units/kg three times weekly IV or subcutaneously
• If hemoglobin approaches or exceeds 11 g/dL, reduce or interrupt dose

For adult patients with CKD not on dialysis: 7

• Consider initiating only when hemoglobin <10 g/dL
• Reduce or interrupt if hemoglobin exceeds 10 g/dL
• Use lowest dose sufficient to reduce need for RBC transfusions

Monitoring requirements: 7

• Monitor hemoglobin weekly until stable, then at least monthly
• Avoid dose increases more frequently than once every 4 weeks
• If hemoglobin rises >1 g/dL in any 2-week period, reduce dose by 25%

Mineral and Bone Disease Management

Monitor and treat CKD-mineral and bone disorder (CKD-MBD) complications. 8, 1

Monitoring frequency in CKD Stage 5: 8

• Serum calcium and phosphorus: every 1-3 months
• PTH: every 3-6 months
• Alkaline phosphatase: annually or more frequently if PTH elevated

Treatment approach: 1

• Treat elevated PTH >300 pg/mL with calcitriol or analogs
• Manage adynamic bone disease by decreasing or eliminating calcium-based phosphate binders and vitamin D
• Correct vitamin D deficiency using treatment strategies recommended for general population 8

Additional Medical Management

Metabolic acidosis management: 9, 6

• Monitor and treat metabolic acidosis to prevent complications
• Required for all patients with advanced CKD

Hyperkalemia management: 9, 6

• Continuous monitoring essential
• Dietary potassium restriction
• Avoid potassium-sparing medications

Hyperphosphatemia management: 9, 6

• Phosphate binders as needed
• Dietary phosphorus restriction

Critical Pitfalls to Avoid

Never rely on serum creatinine alone—always calculate eGFR using validated equations (MDRD or CKD-EPI) that account for age, sex, race, and body size. 1, 2, 3

Do not initiate dialysis based on GFR threshold alone without clinical symptoms. 1, 2, 3 The IDEAL trial demonstrated that early dialysis initiation (at eGFR >10 mL/min/1.73 m²) provides no morbidity or mortality benefit compared to waiting for clinical symptoms. 3

Absolutely avoid NSAIDs entirely in CKD Stage 5 as they worsen renal function and increase hyperkalemia risk. 1, 2, 9

Do not discontinue ACE inhibitors/ARBs prematurely when creatinine rises <30% as initial rises are expected and do not indicate harm. 1, 2

Never use thiazide diuretics when GFR <30 mL/min as they are ineffective at this level of renal function. 2

Never use subclavian vein catheters or PICCs in CKD patients as they compromise future vascular access options. 1

Avoid late referral to nephrology (less than 1 year before RRT need) as this is associated with worse outcomes, higher costs, and inadequate preparation for RRT. 2, 3, 4

Multidisciplinary Care Requirements

All CKD Stage 5 patients require multidisciplinary team management including: 2, 4

• Nephrologist
• Nephrology nurse
• Dietitian for nutritional counseling
• Social worker for psychosocial support
• Patient education about all RRT modalities

Creation of multidisciplinary ACKD units is cost-effective and improves outcomes. 4

Prognosis Counseling

CKD Stage 5 patients face extremely high cardiovascular mortality risk. 1, 2

• 3-year survival on dialysis: only 55%
• 5-year survival on dialysis: only 40%
• Cardiovascular disease is the primary cause of mortality
• Preemptive transplantation offers superior outcomes compared to dialysis-first approaches