What questions should be asked when taking the history of a Chronic Kidney Disease (CKD) stage 5 patient, particularly an older adult with a history of chronic conditions such as diabetes or hypertension?

Essential History Questions for CKD Stage 5 Patients

When evaluating a CKD stage 5 patient, your history must systematically identify the underlying cause, assess readiness for renal replacement therapy, evaluate symptom burden, and screen for life-threatening complications that require immediate intervention.

Establish Etiology and Disease Chronicity

Primary Causes

• Diabetes history: Ask about duration of diabetes (type 1 typically develops CKD after 10 years; type 2 may have CKD at diagnosis), glycemic control history, and presence of other microvascular complications (retinopathy, neuropathy) 1, 2
• Hypertension history: Duration of hypertension, control over time, and presence of end-organ damage (prior stroke, coronary disease, heart failure) 1, 2
• Family history: Specifically ask about kidney failure in family members, polycystic kidney disease, and hereditary nephropathies 2, 3
• Glomerulonephritis: History of hematuria, prior kidney biopsies, autoimmune diseases, or hepatitis B/C 3

Confirm Chronicity

• Review prior laboratory values: When was kidney function last normal? Document progression rate by reviewing historical eGFR and creatinine values 3
• Prior imaging: Ask about previous kidney ultrasounds showing small kidneys (suggests chronicity) versus normal-sized kidneys (may indicate diabetic kidney disease, infiltrative disorders, or acute-on-chronic disease) 2

Assess Preparation for Kidney Failure

Education and Treatment Planning

• Prior nephrology care: When were they first referred to nephrology? Patients known to nephrology before reaching stage 5 survive longer (median 32 vs 15 months) 1, 4
• Knowledge of treatment options: Have they received education about hemodialysis (in-center vs home), peritoneal dialysis, kidney transplantation, and conservative management? 1
• Vascular access planning: For hemodialysis candidates, has arteriovenous fistula or graft been created? 1
• Transplant evaluation: Have they been evaluated for or listed for kidney transplantation? 1

Evaluate Uremic Symptom Burden

High-Prevalence Symptoms (Present in >50% of Stage 5 Patients)

• Fatigue: Lack of energy (reported by 76% of conservatively managed stage 5 patients) 5
• Pruritus: Itching (74% prevalence) 5
• Drowsiness: Excessive daytime sleepiness (65% prevalence) 5
• Dyspnea: Shortness of breath at rest or with exertion (61% prevalence) 5
• Edema: Swelling of legs, ankles, or face (58% prevalence) 5
• Pain: Location, severity, and character (53% prevalence, with 32% reporting moderate-to-severe pain) 5
• Dry mouth and poor appetite: (50% and 47% prevalence respectively) 5
• Muscle cramps and restless legs: (50% and 48% prevalence respectively) 5

Additional Uremic Manifestations

• Cognitive symptoms: Poor concentration, confusion, or altered mental status 1, 5
• Gastrointestinal: Nausea, vomiting, metallic taste, ammonia breath 6
• Sleep disturbance: Insomnia or disrupted sleep (41% prevalence) 5
• Constipation: (35% prevalence) 5

Screen for Life-Threatening Complications

Volume Status and Cardiovascular

• Fluid overload: Orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, weight gain 1
• Hypertension control: Current blood pressure readings, medication adherence 1, 7
• Cardiovascular disease: History of myocardial infarction, heart failure, arrhythmias (cardiovascular disease is the leading cause of death in stage 5 CKD) 1, 6

Metabolic Emergencies

• Hyperkalemia symptoms: Muscle weakness, palpitations, cardiac symptoms 6
• Metabolic acidosis: Dyspnea, confusion, Kussmaul respirations 6
• Uremic complications: Pericarditis (chest pain, friction rub), bleeding tendency, seizures 1

Medication and Nephrotoxin Review

Current Medications

• Nephrotoxic agents: NSAIDs, aminoglycosides, calcineurin inhibitors, lithium 1, 3
• Medications requiring dose adjustment: Antibiotics, anticoagulants, diabetes medications 1
• ACE inhibitors/ARBs: Current use and tolerance (should be continued unless contraindicated) 1

Exposures

• Heavy metals, agrochemicals, contaminated water: Occupational or environmental exposures 2

Assess Comorbidities and Functional Status

Diabetes-Specific (if applicable)

• Glycemic control: Recent HbA1c values, frequency of hypoglycemia 1
• Diabetic complications: Retinopathy status (requires annual ophthalmology), neuropathy, foot ulcers 1
• Foot examination history: Prior ulcers, amputations, peripheral vascular disease 1

Functional and Social Assessment

• Activities of daily living: Ability to perform self-care, mobility limitations 8
• Frailty indicators: Falls, weight loss, weakness (particularly important in elderly patients considering dialysis initiation) 8
• Social support: Caregiver availability, transportation access, housing stability 1
• Quality of life: Patient's goals of care, understanding of prognosis 8

Dietary and Lifestyle Factors

Nutrition

• Sodium and fluid intake: Daily salt consumption, fluid restriction adherence 1
• Protein intake: Excessive protein may accelerate progression 1
• Potassium and phosphorus: Dietary sources that may need restriction 1

Residual Kidney Function

• Urine output: Daily volume (residual kidney function is protective and should be preserved) 1
• Diuretic use: Current regimen if residual function present 1

Timing of Dialysis Initiation

Indications for Urgent Dialysis

• Uremic symptoms: Pericarditis, encephalopathy, bleeding, intractable nausea/vomiting 1, 8
• Fluid overload: Refractory to medical management 1, 8
• Severe metabolic derangements: Hyperkalemia, metabolic acidosis unresponsive to treatment 1, 8
• Malnutrition: Progressive despite dietary intervention 1

Conservative Management Considerations

• Asymptomatic patients: Dialysis may be safely delayed until eGFR 5-7 mL/min/1.73 m² with careful monitoring 8
• Elderly/frail patients: Discuss conservative care as alternative to dialysis, as outcomes and quality of life may be worse with dialysis in this population 8, 4
• Patient preferences: Goals of care, understanding of prognosis (median survival 21 months for conservatively managed stage 5 CKD) 4

Common Pitfalls to Avoid

• Do not rely solely on eGFR to determine dialysis timing; symptom assessment is paramount, as early dialysis initiation (eGFR >10 mL/min/1.73 m²) shows no mortality benefit 8
• Do not overlook pain assessment: Pain is disproportionately severe in stage 5 CKD (32% report moderate-to-severe pain) and requires specific inquiry 5
• Do not assume all symptoms are uremic: Evaluate for other treatable causes (infection, medication side effects, depression) 5
• Do not discontinue ACE inhibitors/ARBs for minor creatinine increases (<30%) in the absence of volume depletion 2
• Do not delay nephrology referral: Patients known to nephrology before stage 5 have significantly better survival 4