What is the appropriate management for a patient with stage 5 chronic kidney disease (end‑stage renal disease)?

Management of Stage 5 Chronic Kidney Disease

Patients with stage 5 CKD (eGFR <15 mL/min/1.73 m²) require immediate nephrology referral if not already under specialist care, followed by evaluation for kidney replacement therapy options—including preemptive transplantation, hemodialysis, peritoneal dialysis, or conservative management—with the specific treatment choice guided by clinical symptoms, comorbidities, and patient preferences rather than GFR threshold alone. 1, 2, 3

Immediate Assessment and Referral

• All stage 5 CKD patients must be under nephrology care within a multidisciplinary team. If not already referred, immediate consultation is mandatory because referral should have occurred at stage 4 (GFR <30 mL/min/1.73 m²) at least 1 year before anticipated need for renal replacement therapy. 2, 3

• Evaluate for absolute indications requiring urgent dialysis initiation: uremic symptoms (pericarditis, encephalopathy, bleeding), diuretic-refractory pulmonary edema, severe hyperkalemia (>6.0 mmol/L) unresponsive to medical therapy, or severe metabolic acidosis. 1, 2, 3

Treatment Modality Selection Algorithm

First Priority: Preemptive Kidney Transplantation

Preemptive kidney transplantation is the optimal choice for appropriate candidates and should be pursued aggressively. 2, 4

Eligibility criteria include:

• Patient at early stage 5 or late stage 4 (GFR <20 mL/min/1.73 m²) with progressive, irreversible CKD over 6-12 months 3, 4
• No urgent uremic symptoms requiring immediate dialysis 2, 4
• Availability of living donor or very short deceased donor wait time 2, 4
• Completion of comprehensive transplant evaluation (cardiac screening, infectious disease workup, psychosocial assessment) 4

Advantages over dialysis-first approach:

• Avoids dialysis-associated cardiovascular stress and complications 2, 4
• Preserves residual kidney function longer 2, 4
• Superior quality of life and survival outcomes (3-year survival 55% on dialysis vs. significantly higher with preemptive transplant) 2

Second Priority: Dialysis Modality Selection

Dialysis should be initiated based on clinical symptoms, not GFR threshold alone. Starting dialysis at higher eGFR values without symptoms does not improve survival and may accelerate loss of residual kidney function, particularly with hemodialysis-related hypotension. 1, 2, 3

Clinical indications for dialysis initiation:

• Uremic symptoms: nausea, vomiting, pruritus, altered mental status, pericarditis 1, 2, 3
• Refractory fluid overload despite maximal diuretic therapy 1, 2, 3
• Uncontrolled hypertension despite multiple agents 1, 2, 3
• Progressive malnutrition or protein-energy wasting 1, 2, 3
• Severe electrolyte disturbances (hyperkalemia >6.0 mmol/L refractory to treatment) 1, 2, 3
• Uremic bleeding or coagulopathy 1, 3

Hemodialysis

Vascular access planning must begin immediately if not already done. 2

Access options in order of preference:

• Arteriovenous fistula (AVF): Preferred access requiring 6-8 months for maturation; plan placement when GFR approaches 20-25 mL/min/1.73 m² 2, 5
• Arteriovenous graft (AVG): Alternative if veins inadequate for fistula; usable in 24 hours to 2 weeks depending on graft material 2, 5
• Central venous catheter: Usable immediately but highest infection risk; use only as bridge to permanent access 2, 5

Critical pitfall: Never use subclavian vein catheters or PICCs in CKD patients, as they cause central vein stenosis that compromises future fistula creation. 2

Peritoneal Dialysis

Advantages include:

• Home-based therapy with greater schedule flexibility 1, 2
• Preserves residual kidney function longer than hemodialysis 1, 2
• No vascular access needed 2
• Better hemodynamic stability (no rapid fluid shifts) 1

Requirements:

• Comprehensive patient education and training on technique, infection prevention, and catheter care 2
• Adequate manual dexterity and cognitive function (or trained caregiver) 1
• Suitable home environment and storage space 1

Third Priority: Conservative Management Without Dialysis

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

Appropriate candidates include:

• Patients with multiple comorbidities and limited life expectancy 2, 3
• Advanced age with frailty 2, 3
• Those who decline dialysis after informed decision-making 1, 2

Conservative management components:

• Low-protein diet (0.6-0.8 g/kg/day) with keto-analogs of essential amino acids 1, 3
• Loop diuretics for volume control 1
• Sodium polystyrene sulfonate for hyperkalemia management 1
• Palliative care principles and hospice referral when appropriate 1, 2
• Maximize quality of life through symptom management 1, 2

Medical Management During Stage 5 CKD

Blood Pressure and Cardiovascular Control

Target blood pressure <130/80 mmHg using ACE inhibitors or ARBs as first-line therapy. 2, 3

ACE inhibitor/ARB management:

• Continue ACE inhibitors/ARBs in stage 5 CKD unless dialysis has been initiated or intolerable adverse effects occur. This represents current KDIGO 2024 guidance. 3
• Monitor serum creatinine and potassium within 5-7 days after initiating or adjusting doses 2, 3
• Continue therapy if creatinine rises <30% from baseline within first 4 weeks (reflects hemodynamic effect, not renal injury) 3
• Discontinue or reduce dose if: creatinine rises >30% from baseline, potassium >5.5 mmol/L despite management, or symptomatic hypotension develops 2, 3

Critical pitfall: Do not discontinue ACE inhibitors/ARBs prematurely when creatinine rises <30%, as initial rises are expected and do not indicate harm. 2, 3

Anemia Management

Start erythropoietin-stimulating agents when hemoglobin falls between 9.0-10.0 g/dL to avoid dropping below 9.0 g/dL. 2

• Target hemoglobin 11.0-12.0 g/dL in adults 2
• Monitor blood pressure with each erythropoietin dose, as hypertension is a common adverse effect 1
• Ensure adequate iron stores before initiating therapy 2

Mineral and Bone Disease Management

Monitor calcium, phosphorus, and intact PTH at least every 3 months. 1, 3

Management targets:

• Limit dietary phosphorus to 800-1,000 mg/day 3
• Use phosphate binders with meals if hyperphosphatemia persists 2
• Treat elevated PTH >300 pg/mL with calcitriol or analogs 2
• Manage adynamic bone disease by decreasing or eliminating calcium-based phosphate binders and vitamin D 2

Metabolic Acidosis Management

Monitor serum bicarbonate at least every 3 months. 1, 3

• Correct chronic metabolic acidosis to serum bicarbonate ≥22 mmol/L using oral sodium bicarbonate 1
• Typical starting dose: 650-1,300 mg (1-2 tablets) three times daily, titrated to target 1

Nutritional Management

Dietary protein restriction to 0.8 g/kg/day for patients not yet on dialysis. 3

Additional dietary restrictions:

• Sodium: <2 g/day (equivalent to <5 g sodium chloride/day) 3
• Potassium: 2-3 g/day if hyperkalemia develops 3
• Phosphorus: 800-1,000 mg/day 3

Monitor serum albumin every 3 months to evaluate nutritional status. 3

Hyperkalemia Management

Avoid NSAIDs entirely, as they worsen renal function and increase hyperkalemia risk. 2, 3

Hyperkalemia treatment strategies without stopping ACE inhibitors/ARBs:

• Dietary potassium restriction (2-3 g/day) 3
• Loop diuretics to enhance potassium excretion 1
• Sodium polystyrene sulfonate (15-30 g orally 1-4 times daily) 1
• Newer potassium binders (patiromer, sodium zirconium cyclosilicate) if available 3

Monitoring Schedule for Stage 5 CKD

Establish the following monitoring intervals: 3

• Serum creatinine and eGFR: every 3 months 3
• Serum potassium: every 3 months (more frequently if on ACE inhibitors/ARBs) 3
• Hemoglobin: every 3 months 3
• Calcium, phosphorus, and PTH: every 3-6 months 1, 3
• Serum bicarbonate: every 3 months 1, 3
• Serum albumin: every 3 months 3

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. 2, 3

Do not initiate dialysis based on GFR threshold alone without clinical symptoms. Early dialysis initiation does not improve outcomes and may accelerate loss of residual kidney function. 1, 2, 3

Avoid NSAIDs entirely in stage 5 CKD. They worsen renal function, increase hyperkalemia risk, and accelerate progression. 2, 3

Do not use thiazide diuretics when GFR <30 mL/min. They are ineffective at this level of renal function; use loop diuretics instead. 3

Never place subclavian vein catheters or PICCs in CKD patients. They cause central vein stenosis that compromises future arteriovenous fistula creation. 2

Do not delay nephrology referral. Referral at stage 4 (GFR <30 mL/min/1.73 m²) at least 1 year before anticipated RRT need is essential to avoid "late referral" complications, including inadequate vascular access, suboptimal dialysis initiation, and missed transplant opportunities. 2, 3, 4

Medication Adjustments in Stage 5 CKD

Specific drug considerations: 3

• Metformin: Contraindicated when eGFR <30 mL/min/1.73 m²; discontinue in stage 5 CKD 3
• Opioid analgesics: Use with extreme caution; markedly reduce doses to prevent accumulation and toxicity 3
• Benzylpenicillin: Maximum 6 g/day due to neurotoxicity risk 3
• Tetracycline antibiotics: Require dose reduction; can worsen uremia 3

Prognosis and Patient Counseling

Stage 5 CKD patients on dialysis have 3-year survival of only 55% and 5-year survival of 40%, primarily due to cardiovascular mortality. 2

Preemptive transplantation offers superior outcomes compared to dialysis-first approaches. 2, 4

Cardiovascular disease is the leading cause of death in stage 5 CKD, not uremia. Aggressive cardiovascular risk factor management (blood pressure, lipids, diabetes control) is essential. 1, 2