Medical Management of CKD Stage V Patients
For patients with CKD Stage V (GFR <15 mL/min/1.73 m²), initiate dialysis based on clinical symptoms rather than GFR alone—specifically when uremic symptoms appear (serositis, refractory acid-base/electrolyte abnormalities, pruritus), volume status cannot be controlled, blood pressure remains uncontrolled despite multiple agents, nutritional status progressively deteriorates despite dietary intervention, or cognitive impairment develops, which typically occurs when GFR is between 5-10 mL/min/1.73 m². 1
Renal Replacement Therapy Decision-Making
Timing of RRT Initiation
Do not initiate dialysis based solely on a GFR threshold without accompanying uremic symptoms, as early initiation without symptoms increases mortality risk without improving outcomes. 1, 2
Consider timely referral for RRT planning when the validated risk prediction model indicates ≥10-20% risk of kidney failure within 1 year. 1
For living donor preemptive kidney transplantation, begin evaluation when GFR falls below 20 mL/min/1.73 m² with documented progressive and irreversible CKD over the preceding 6-12 months. 1, 2
RRT Modality Selection
Transplantation remains the preferred RRT option when feasible, offering superior mortality and quality of life outcomes compared to dialysis. 2
For dialysis modality choice, no mortality difference exists between peritoneal dialysis and hemodialysis, so selection should account for patient lifestyle, home environment, manual dexterity, and vascular access feasibility. 3
Prepare vascular access early: arteriovenous fistulas require several months to mature before use, arteriovenous grafts can be used within 24 hours depending on material, and central venous catheters (highest infection risk) are immediately usable but should be avoided as permanent access. 3
Multidisciplinary Care Requirements
Manage progressive CKD Stage V patients in a multidisciplinary setting that includes dietary counseling, education about all RRT modalities (hemodialysis, peritoneal dialysis, transplantation), vascular access surgery planning, and psychological/social support. 1, 2
Ensure access to advance care planning discussions, including the option of conservative management without dialysis for patients who decline RRT. 1
Medication Management in CKD Stage V
Cardiovascular Risk Reduction
Do NOT initiate statin therapy or combination statin/ezetimibe therapy in dialysis-dependent CKD Stage V patients, as evidence shows no ASCVD risk reduction benefit in this population. 1
However, continue statin therapy in patients already receiving it at the time dialysis is initiated. 1
Target systolic blood pressure <120 mmHg using standardized office measurement when tolerated, avoiding NSAIDs due to nephrotoxicity risk. 4
Anemia Management
Monitor hemoglobin at least every 3 months when GFR ≤30 mL/min/1.73 m². 1
Initiate workup for anemia (including iron studies) when hemoglobin falls below 12 g/dL in women or 13 g/dL in men. 1
Evaluate and correct iron deficiency before starting erythropoiesis-stimulating agents (ESAs): administer supplemental iron when serum ferritin <100 mcg/L or transferrin saturation <20%. 5
For adult CKD patients on dialysis, initiate epoetin alfa when hemoglobin <10 g/dL at a starting dose of 50-100 Units/kg three times weekly intravenously (preferred route for hemodialysis patients). 5
Target hemoglobin levels that reduce transfusion need but avoid exceeding 11 g/dL, as higher targets increase risks of death, serious cardiovascular events, and stroke. 5
Monitor blood pressure with each ESA dose, as hypertension is a common adverse effect. 1
Mineral and Bone Disorder Management
Monitor serum calcium and phosphorus at least every 3 months when GFR ≤30 mL/min/1.73 m². 1
Measure intact parathyroid hormone (iPTH) at least once initially, then every 3 months if calcium or phosphorus levels are abnormal. 1
When iPTH ≥100 pg/mL (or 1.5× upper limit of normal) OR serum phosphorus ≥4.5 mg/dL, initiate a low phosphorus diet (800-1000 mg/day) for one month. 1
If serum phosphorus remains ≥4.5 mg/dL after dietary intervention, start phosphate binders and continue monitoring iPTH every 3 months regardless of phosphorus control. 1
Metabolic Acidosis Management
Monitor serum bicarbonate at least every 3 months when GFR ≤30 mL/min/1.73 m². 1
Correct chronic metabolic acidosis to maintain serum bicarbonate ≥22 mmol/L using pharmacological treatment with or without dietary intervention. 1
Avoid correcting bicarbonate above the upper limit of normal, and monitor for adverse effects on blood pressure, serum potassium, and fluid status. 1
Hyperkalemia Management
Monitor serum potassium regularly, especially in patients on RAS inhibitors or with eGFR <30 mL/min/1.73 m². 6
For emergent hyperkalemia in CKD G3-G5, implement individualized dietary restrictions (limiting bioavailable potassium from processed foods) combined with pharmacologic interventions. 1
Avoid NSAIDs entirely due to hyperkalemia risk and nephrotoxicity. 4
Volume Management
Initiate loop diuretics as first-line treatment for edema, using twice-daily dosing rather than once-daily dosing for better efficacy in reduced GFR. 4
Restrict dietary sodium to <2.0 g/day (<90 mmol/day) as essential adjunct to diuretic therapy. 4
For diuretic-resistant edema, add high-dose thiazide-like diuretics to achieve synergistic distal sodium blockade. 4
Monitor for hypokalemia (with loop/thiazide diuretics), hyponatremia (with thiazides), hyperkalemia (with spironolactone), impaired GFR, and volume depletion, particularly in elderly patients. 4
Glycemic Control in Diabetic Patients
Continue metformin cautiously with dose adjustment based on eGFR, and maintain SGLT2 inhibitor therapy if eGFR ≥20 mL/min/1.73 m². 1
Add long-acting GLP-1 receptor agonist if glycemic targets are not met, prioritizing agents with documented cardiovascular benefits. 1
Conservative Management Option
Offer conservative management without dialysis as a legitimate option for patients who decline RRT, particularly those aged ≥75 years with multiple comorbidities, frailty, significant functional impairment, cognitive impairment, or limited life expectancy. 1, 2
Provide comprehensive conservative care including protocols for symptom management, pain control, psychological support, spiritual care, culturally sensitive end-of-life care, and bereavement support. 1
Ensure coordinated palliative care and hospice referral for patients choosing conservative management or discontinuing dialysis. 3
Critical Pitfalls to Avoid
Never initiate dialysis based on GFR alone without uremic symptoms present, as this increases mortality without benefit. 1, 2
Never fail to discuss all RRT options including transplantation, both dialysis modalities, and conservative management—offering only one modality constitutes inadequate counseling. 1, 2
Never start statins in dialysis-dependent patients, as cardiovascular events in this population are predominantly non-atherosclerotic (heart failure and arrhythmias rather than plaque rupture). 1
Never target hemoglobin >11 g/dL with ESAs, as this significantly increases mortality and cardiovascular event risk. 5
Never use NSAIDs for pain management in CKD Stage V—utilize non-pharmacologic interventions, acetaminophen, or carefully dose-adjusted opioids instead. 4