Pre-Hemodialysis Assessment for Stage 5 CKD
All adults with stage 5 CKD (eGFR <15 mL/min/1.73 m²) planning in-center hemodialysis require immediate nephrology referral if not already established, multidisciplinary team evaluation, vascular access planning, comprehensive laboratory monitoring, and symptom-based dialysis timing—not GFR-based initiation. 1
Immediate Nephrology Referral and Multidisciplinary Team
Refer immediately to nephrology if the patient is not already under nephrology care, as consultation at eGFR <30 mL/min/1.73 m² reduces costs, improves quality of care, and delays dialysis initiation. 2
Establish multidisciplinary care that includes or provides access to: 3, 1
- Dietary/nutritional counseling
- Education about all RRT modalities (hemodialysis, peritoneal dialysis, transplantation)
- Vascular access surgery consultation
- Psychological and social support services
- Conservative management counseling
Multidisciplinary care significantly slows eGFR decline regardless of CKD stage or primary disease, and is recommended for all patients with CKD stage 3-5. 4
Verify True Renal Function
Obtain measured GFR using 24-hour urine collection for creatinine and urea clearances rather than relying solely on estimated GFR, particularly in patients with unusual creatinine generation (very muscular or malnourished individuals) or altered tubular secretion. 2, 5
Calculated eGFR equations can differ markedly from actual GFR in clinically important ways, especially in stage 5 CKD where dialysis initiation decisions are critical. 5
Comprehensive Laboratory Monitoring Schedule
Monitor the following parameters at specified intervals: 1
- Serum creatinine and eGFR: every 3 months
- Serum potassium: every 3 months (more frequently if on ACE inhibitors/ARBs)
- Hemoglobin: every 3 months to screen for CKD-related anemia
- Calcium, phosphorus, and PTH: every 3-6 months for mineral-bone disorder management
- Serum albumin: every 3 months to evaluate nutritional status
Vascular Access Planning
Initiate vascular access planning immediately for patients planning in-center hemodialysis, as preparation must begin at least 1 year before anticipated RRT initiation to avoid "late referral" complications. 1
Most patients who present without pre-dialysis planning require central venous catheter placement (often non-tunneled), which is associated with higher morbidity and mortality compared to arteriovenous fistula or graft. 6
Blood Pressure and Cardiovascular Management
Target blood pressure <130/80 mmHg using ACE inhibitor or ARB as first-line therapy for blood pressure control and kidney protection. 1, 2
Do not routinely discontinue ACE inhibitors/ARBs at eGFR <15 mL/min/1.73 m² unless dialysis has been initiated or intolerable adverse effects occur. 1
After initiating or adjusting ACE inhibitor/ARB, measure serum creatinine and potassium within 5-7 days, then repeat 2-4 weeks later. 1
Continue therapy if creatinine rise is <30% within the first 4 weeks, as this reflects hemodynamic effect rather than renal injury. 1
Discontinue or reduce dose if: 1
- Creatinine increases >30% from baseline within 4 weeks
- Potassium exceeds 5.5 mmol/L despite management
- Symptomatic hypotension develops
Nutritional Assessment and Counseling
Limit protein intake to 0.8 g/kg/day for patients with stage 5 CKD not yet on dialysis. 1
Restrict sodium to <2 g/day (equivalent to <5 g sodium chloride). 1
Limit potassium to 2-3 g/day if hyperkalemia develops. 1
Restrict phosphorus to 800-1,000 mg/day to prevent renal osteodystrophy. 1
Assess for protein-energy malnutrition using serum albumin every 3 months, as progressive malnutrition is an indication for dialysis initiation. 1
Structured Patient Education
Provide comprehensive education about: 2, 7
- The progressive nature of kidney disease
- All RRT modality options (in-center hemodialysis, home hemodialysis, peritoneal dialysis, kidney transplantation)
- Conservative management without dialysis as a valid option
- Living donor preemptive transplantation (should be considered when GFR <20 mL/min/1.73 m² with evidence of progressive, irreversible CKD over 6-12 months) 3, 1
Encourage maintenance of employment and normal activities as long as possible. 2
Assessment of Comorbidities and Complications
Evaluate and manage the following CKD complications: 8
- Anemia: Most patients (98.17%) have anemia at dialysis initiation, with average hemoglobin 8.69±1.85 g/dL. 6
- Hyperkalemia: Monitor closely, especially in patients on ACE inhibitors/ARBs
- Metabolic acidosis: Assess serum bicarbonate
- Hyperphosphatemia and secondary hyperparathyroidism: Monitor calcium, phosphorus, PTH
- Vitamin D deficiency: Screen and supplement as needed
- Cardiovascular disease: High blood pressure, ischemic heart disease, heart failure, history of myocardial infarction or stroke, peripheral artery disease, atrial fibrillation 6
Clinical Assessment for Dialysis Timing
Dialysis should be initiated based on clinical symptoms, NOT GFR alone. 3, 1, 2, 7
Absolute indications for dialysis initiation include: 1, 2, 7
Uremic symptoms: serositis (pericarditis, pleuritis), pruritus, nausea, vomiting, altered mental status, cognitive impairment, peripheral neuropathy
Volume overload refractory to diuretic therapy
Uncontrolled hypertension despite maximal medical management
Progressive malnutrition or protein-energy wasting despite dietary intervention
Severe electrolyte abnormalities: hyperkalemia >6.0 mmol/L refractory to treatment, severe metabolic acidosis
Uremic bleeding or coagulopathy
These symptoms typically occur when GFR is between 5-10 mL/min/1.73 m², but dialysis initiation at higher eGFR thresholds in the absence of symptoms does not improve survival and may accelerate loss of residual kidney function. 3, 1
Conservative Management Discussion
Discuss conservative management without RRT with all stage 5 CKD patients as a valid option, particularly appropriate for those with multiple comorbidities, advanced age, or frailty. 3, 1, 2
Conservative management should be supported by comprehensive protocols for symptom and pain management, psychological care, spiritual care, and culturally sensitive end-of-life care. 3
Critical Pitfalls to Avoid
Never initiate dialysis based on GFR threshold alone without clinical symptoms, as early dialysis initiation does not improve outcomes and may cause harm. 1, 2
Never rely solely on serum creatinine—always calculate eGFR using validated equations (MDRD or CKD-EPI) that account for age, sex, race, and body size. 1
Avoid NSAIDs entirely in stage 5 CKD, as they worsen renal function and increase hyperkalemia risk. 1
Do not discontinue ACE inhibitors/ARBs prematurely when creatinine rises <30%, as initial rises are expected and do not indicate harm. 1
Never use thiazide diuretics when eGFR <30 mL/min/1.73 m², as they are ineffective at this level of renal function. 1
Avoid aggressive first dialysis sessions—use a "low and slow" approach with initial session duration of 2-2.5 hours, reduced blood flow rates, and minimal ultrafiltration to prevent dialysis disequilibrium syndrome and hemodialysis-related hypotension. 2