Renal & Urology

End-Stage Renal Disease

Kidney failure is stage 5 chronic kidney disease with insufficient renal function to maintain homeostasis; care is planned around symptoms, biochemical complications, patient goals and the choice between dialysis, transplantation and supported conservative management.

In a nutshell

Kidney failure is CKD G5 (eGFR below 15), but dialysis is not started from eGFR alone. Plan early for transplant, haemodialysis, peritoneal dialysis or active conservative management. Dialyse for uraemic symptoms, uncontrolled fluid overload or biochemical complications; consider around eGFR 5 to 7 without symptoms. Urgently refer refractory hyperkalaemia, acidosis, uraemic pericarditis/encephalopathy, fluid overload or pulmonary oedema.

Classic presentation

A person with progressive CKD develops anorexia, nausea, pruritus, fatigue, oedema, breathlessness, anaemia, hyperkalaemia and acidosis, and needs a shared decision about renal replacement or conservative care.

Key points

G5 is eGFR below 15 mL/min/1.73 m2; eGFR alone does not determine dialysis.
Plan RRT or conservative management at least 1 year before it is likely to be needed.
Transplantation offers the best survival and quality-of-life outcomes for suitable people; consider pre-emptive transplant.
If haemodialysis is chosen, aim to create an AV fistula around 6 months before anticipated dialysis when suitable.
Start dialysis for uraemic symptoms, biochemical measures or uncontrollable fluid overload; consider eGFR 5 to 7 without symptoms.
Refractory hyperkalaemia, acidosis, uraemic pericarditis/encephalopathy, fluid overload or pulmonary oedema require immediate renal/critical-care referral.
Conservative management is active, supported, person-centred care.

First-line investigation

Serial eGFR and U&E with potassium/bicarbonate, symptom and fluid assessment, FBC/iron, calcium/phosphate/PTH, urinalysis/ACR and cause/chronicity assessment.

Management

Recognise urgent complications

Refractory hyperkalaemia, acidosis, uraemic pericarditis/encephalopathy, fluid overload or pulmonary oedema require immediate nephrology/critical-care referral for RRT.³

Plan before crisis

Start shared assessment for transplant, haemodialysis, peritoneal dialysis or conservative care at least 1 year before likely RRT.²
Assess eGFR trend, symptoms, fluid, potassium, bicarbonate, anaemia and mineral-bone disorder; do not use one result in isolation.^2,1

Start the chosen RRT

Dialysis is driven by symptomatic uraemia, biochemical measures or uncontrollable fluid overload; around eGFR 5 to 7 without symptoms is a consideration, not an automatic trigger.²

Protect long-term goals

Monitor access, dialysis adequacy, anaemia, phosphate/calcium/PTH, nutrition, cardiovascular risk and psychological wellbeing, with ongoing review of transplant or conservative-care goals.^2,1

Exam traps

Do not start dialysis from eGFR alone.
Do not delay emergency referral for refractory hyperkalaemia, acidosis, pulmonary oedema or uraemic complications while waiting for a planned dialysis date.
Do not describe conservative management as non-treatment.
Do not start ESA without addressing absolute iron deficiency.
Do not assume one dialysis modality or a fixed weekly schedule suits every patient.
Do not forget superimposed AKI, obstruction, nephrotoxicity or sepsis.

Illustrations

Arteriovenous fistula during haemodialysisA forearm arteriovenous fistula connected to a haemodialysis circuit, with the image labelled as planned vascular access rather than a substitute for access assessment.Anna Frodesiak, Wikimedia Commons · CC0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.