Is chronic kidney disease stage 5 considered end‑stage renal disease (ESRD)?

CKD Stage 5 and ESRD/ESRF: Terminology and Clinical Equivalence

Yes, CKD Stage 5 is clinically equivalent to what was historically called end-stage renal failure (ESRF) or end-stage renal disease (ESRD), but modern guidelines explicitly recommend abandoning the "end-stage" terminology in favor of "kidney failure" or "CKD Stage 5." 1

Why the Terminology Has Changed

The KDIGO 2020 consensus conference unanimously agreed that "kidney failure" should replace all "end-stage" terminology because ESRD/ESRF are poorly defined, inconsistently used, and misleadingly imply that death is imminent even though patients can survive for years with treatment. 1, 2

• The terms ESRD and ESRF are explicitly listed as "terms to avoid" in the KDIGO nomenclature guidelines. 1, 2
• These terms carry stigma and create confusion because they are used administratively (for Medicare coverage eligibility in the US) rather than as precise medical definitions. 2
• ESRD/ESRF technically only applies to patients receiving dialysis or transplantation, excluding patients with identical kidney dysfunction who are not treated by choice, lack of access, or who receive conservative management. 2

The Correct Modern Definition

CKD Stage 5 (kidney failure) is defined as GFR <15 mL/min/1.73 m² or treatment by dialysis, representing loss of more than 85% of kidney function. 1, 3, 2

• This definition applies regardless of whether the patient is receiving kidney replacement therapy. 1
• Further specification is required beyond just the GFR threshold: duration of disease (>3 months to distinguish from acute kidney injury), presence or absence of uremic symptoms, and treatment status. 1, 3

How to Properly Document CKD Stage 5

Use the nomenclature "CKD G5" with additional descriptors to specify treatment status: 1, 2

• CKD G5D = CKD Stage 5 treated by dialysis (replaces "ESRD on dialysis") 1
• CKD G1T–G5T = CKD after kidney transplantation at any GFR level (replaces "ESRD with transplant") 1
• CKD G5 without KRT = Kidney failure not receiving kidney replacement therapy, whether by patient choice, unavailability, or comprehensive conservative care 1, 3

Clinical Implications of the Distinction

The shift from ESRD/ESRF to CKD Stage 5 terminology reflects that kidney failure is a clinical state requiring specification of symptoms and treatment, not just a GFR threshold. 3, 2

• Patients with GFR <15 mL/min/1.73 m² may remain stable without dialysis for months to years, particularly with multidisciplinary nephrology care including dietary counseling, RAS blockade, and symptom management. 3, 4, 5
• Dialysis initiation should be based on clinical symptoms (uremic symptoms, refractory fluid overload, uncontrolled hypertension, progressive malnutrition, severe electrolyte abnormalities) rather than GFR threshold alone. 3
• Starting dialysis at higher GFR values in asymptomatic patients does not improve survival and may accelerate loss of residual kidney function due to hemodialysis-related hypotension. 3

Common Pitfalls to Avoid

Never use ESRD, ESRF, ESKD, or ESKF in clinical documentation—these are outdated terms that KDIGO explicitly recommends avoiding. 1, 2

Do not assume all patients with GFR <15 mL/min/1.73 m² are receiving or need dialysis—always specify treatment status explicitly. 2

Do not initiate dialysis based solely on reaching GFR <15 mL/min/1.73 m² without clinical symptoms, as this threshold alone does not mandate treatment. 3

Always calculate eGFR using validated equations (MDRD or CKD-EPI) rather than relying on serum creatinine alone, as creatinine-based estimates can overestimate residual renal function when GFR is severely impaired in up to 36% of cases. 3, 6