II. Definitions

  1. Chronic Kidney Disease
    1. Abnormal Kidney structure or function lasting more than 3 months, with associated health implications
    2. Estimated Glomerular Filtration Rate (eGFR) <60 ml/min OR
    3. Positive Kidney damage markers (e.g. albuminuria) OR
    4. Polycystic or dysplastic Kidneys
  2. End Stage Renal Disease
    1. Kidney Function not adequate for longterm survival without Dialysis or Renal Transplant
    2. Stage 5 Chronic Kidney Disease (GFR <15 ml/min/1.73m2)

III. Causes

IV. Findings

VI. Management: Renal Replacement

  1. See Chronic Kidney Disease for secondary prevention
  2. Hemodialysis or Peritoneal Dialysis
    1. See Hemodialysis
    2. See Peritoneal Dialysis
    3. Absolute Dialysis Indications
      1. Uremic Symptoms
      2. Uremic Pericarditis
    4. Relative Dialysis Indications
      1. Hypervolemia
      2. Hyperkalemia or other Electrolyte abnormalities
      3. Severe Metabolic Acidosis
      4. Creatinine Clearance <10 ml/min (<15 ml/min in Diabetes Mellitus)
  3. Renal Transplantation
    1. Improves overall survival and quality of life in comparison to Dialysis and conservative management
    2. Refer to Renal Transplant when GFR <30 ml/min/1.73m2 to allow for adequate planning, preparation, wait list time
    3. As of 2020, the median time of Renal Transplant wait list is 4 years
    4. Less rejection if transplant before Dialysis started
      1. Mange (2001) N Engl J Med 344:726-31 [PubMed]
  4. Conservative management options (palliative approach)
    1. Optimizes quality of life over prolongation of life
      1. Survival benefit of Hemodialysis is reduced in elderly and comorbidity
      2. Uremia symptoms may not significantly improve with Hemodialysis
      3. Hemodialysis is associated with increased medical interventions
    2. More than half of chronic Hemodialysis patients regret their decision to undergo Hemodialysis
      1. Davison (2010) Clin J Am Soc Nephrol 5(2): 195-204 [PubMed]
    3. Non-Dialysis with Hospice care
    4. Delayed Dialysis until Creatinine Clearance <5 ml/min (similar morbidity and mortality)
      1. Cooper (2010) N Engl J Med 363(7):609-19 [PubMed]

VII. Management: Anemia in ESRD

  1. Erythropoietin (EPO)
    1. Efficacy
      1. Initial studies showed benefit for Erythropoietin
        1. Renicki (1995) Am J Kidney Dis 25:548-54 [PubMed]
      2. Recent studies show no benefit and higher risk of Cerebrovascular Accident
        1. Outcomes are the same with and without normalized Hemoglobin via erythropoetin
        2. Morbidity and patient sense of well-being is not improved on erythropoetin
        3. Pfeffer (2009) N Engl J Med 361 [PubMed]
    2. Indications for Erythropoeitin
      1. Hemoglobin <9 to 10 mg/dl
      2. Do not target a Hemoglobin >11 mg/dl
    3. Adverse effects
      1. Increased risk of Cerebrovascular Accident
  2. Iron Supplementation
    1. Often indicated in Hemodialysis patients
    2. Parenteral replacement is often needed (decreased oral absorption)
      1. Non-Dextran IV Iron
        1. Indicated in significant Iron Deficiency refractory to oral replacement
        2. Options: Ferumoxytol (Feraheme), iron sucrose (venafer) or Sodium Ferric Gluconate (Ferrlecit)
      2. Ferric pyrophosphate (Triferic)
        1. Available in 2015 (U.S.)
        2. Indicated for maintenance iron infusion
        3. May be delivered inline with Hemodialysis
    3. References
      1. (2015) Presc Lett 22(4)

VIII. Management: Metabolic Bone Disease (Secondary Hyperparathyroidism)

IX. Management: Anorexia and Protein Energy Wasting in ESRD

  1. Minimize Uremia with adequate Dialysis frequency
  2. Consider Major Depression, Gastroparesis, and Xerostomia
  3. Protein Energy Wasting Findings
    1. BMI < 23 kg/m2
    2. Unintentional Weight Loss (>5% over 3 months or >10% over 6 months)
    3. Serum Albumin <3.8 g/dl
  4. General Measures
    1. Dietician Consultation
    2. High Protein diet 1.0 to 1.2 g Protein/kg/day in ESRD
      1. Contrast with the limited Protein diet in Chronic Kidney Disease to prevent progression
      2. Consider dietary Protein Supplementation
  5. Medications
    1. Dronabinol 2.5 mg orally before meals
    2. Megestro 400 mg orally daily
    3. Prednisone 10 mg orally daily

X. Management: Symptomatic Management in ESRD

  1. Agitation
    1. Haloperidol 1 mg PO, IV or IM every 12 hours
  2. Dyspnea
    1. Regular Physical Activity to prevent deconditioning
    2. Fentanyl (Duragesic) 12.5 mg IV or SQ every two hours as needed for end-of-life
  3. Fatigue
    1. Treat Anemia if present
    2. Consider Depression Management with Fluoxetine 20 mg daily or Sertraline 50 mg daily
  4. Nausea and Vomiting
    1. Minimize Uremia with adequate Dialysis frequency
    2. Ondansetron 4 mg orally every 8 hours
    3. Metoclopramide (Reglan) 5 mg twice daily
    4. Haloperidol (Haloperidol) 0.5 mg orally every 8 hours
  5. Pruritus
    1. Minimize Uremia with adequate Dialysis frequency
    2. Phosphate Binders
    3. Standar Dry Skin therapy (e.g. barrier creams)
    4. Ondansetron 4 mg orally every 8 hours
    5. Hydroxyzine (Atarax or Vistaril), 25 mg orally every 6 hours
    6. Naltrexone (Revia) 50 mg orally daily
    7. Phototherapy (UV-B Light)
  6. Insomnia
    1. See Sleep Hygiene
    2. Treat Restless Leg Syndrome
    3. Treat Obstructive Sleep Apnea
    4. Zolpidem 5 mg orally at bedtime
    5. Temazepam (Restoril) 15 mg orally at bedtime

XI. Management: Advanced Directives in ESRD

  1. Cardiopulmonary Resuscitation (CPR)
    1. Survival in ESRD is only 8% at hospital discharge and 3% at six months
    2. Contrast with CPR in non-ESRD with survival of 12% at discharge and 9% at six months
    3. Discuss Do-Not-Reuscitate status at routine visits
  2. Hospice
    1. Criteria to qualify for Hospice services paid by Medicare in End Stage Renal Disease
      1. ESRD on no-Dialysis management or
      2. ESRD on Dialysis and other Hospice qualifying condition (e.g. cancer)

XII. Complications

XIII. Prognosis

  1. See Chronic Kidney Disease for course
  2. Annual mortality of ESRD: 24%
  3. Five Year survival of ESRD
    1. All ages: 38%
    2. Age over 65 years: 18%

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Related Studies

Ontology: Kidney Failure, Chronic (C0022661)

Definition (NCI) Impairment of the renal function due to chronic kidney damage.
Definition (CSP) irreversible and usually progressive reduction in renal function in which both kidneys have been damaged by a variety of diseases to the extent that they are unable to adequately remove the metabolic products from the blood and regulate the body's electrolyte composition and acid-base balance.
Definition (MSH) The end-stage of CHRONIC RENAL INSUFFICIENCY. It is characterized by the severe irreversible kidney damage (as measured by the level of PROTEINURIA) and the reduction in GLOMERULAR FILTRATION RATE to less than 15 ml per min (Kidney Foundation: Kidney Disease Outcome Quality Initiative, 2002). These patients generally require HEMODIALYSIS or KIDNEY TRANSPLANTATION.
Concepts Disease or Syndrome (T047)
MSH D007676
ICD9 585.6
ICD10 N18 , N18.9, N18.0, N18.90
SnomedCT 46177005, 155856009, 197654000, 197755007, 197655004, 90688005
LNC LP146090-8
English Kidney Failure, Chronic, Renal Failure, Chronic, KIDNEY FAILURE CHRONIC, End-Stage Kidney Disease, ESRD, End-Stage Renal Disease, Renal Disease, End-Stage, Renal Failure, End-Stage, Disease, End-Stage Kidney, Disease, End-Stage Renal, End-Stage Renal Failure, Kidney Disease, End-Stage, Renal Disease, End Stage, Renal Failure, End Stage, End Stage Kidney Disease, End Stage Renal Disease, RENAL FAILURE CHRONIC, CRF, Chronic renal failure, unspecified, ESCRF - End stge chr renl fail, End stage renal failure, End-stage renal disease, RENAL FAILURE CHRONIC <UREMIA>, End stage chronic renal failure, End stage chronc renal failure, END STAGE KIDNEY DIS, RENAL DIS END STAGE, END STAGE RENAL DIS, end stage renal failure, chronic renal failure, end stage renal disease, end stage renal disease (diagnosis), chronic renal failure (diagnosis), ESRD (end stage renal disease), Kidney failure chronic, Renal failure chronic, End stage renal disease (ESRD), RENAL FAILURE CHRONIC UREMIA, CRF - Chronic Renal Failure, Chronic renal disease, Chronic renal failure NOS, Kidney Failure, Chronic [Disease/Finding], Unspecified chronic renal failure, chronic kidney insufficiency, Failure;renal;chronic, chronic renal insufficiency, end stage renal disease (ESRD), end-stage renal disease, end-stage renal failure, esrd, chronic kidney failure, end-stage kidney disease, chronic renal failure (CRF), end stage kidney disease, Chronic renal insufficiency, Renal failure, chronic, End-stage renal failure, Renal failure - chronic, Renal failure (chronic), End stage renal failure (disorder), Failure, renal -chronic, Chronic kidney failure, Chronic renal failure, Chronic renal failure syndrome, End-stage kidney disease, End stage renal disease, End stage kidney disease, CRF - Chronic renal failure, ESCRF - End stage chronic renal failure, ESRD - End stage renal disease, ESRF - End stage renal failure, Chronic renal failure syndrome (disorder), End stage renal disease (disorder), disease (or disorder); kidney, end-stage, disease (or disorder); renal, end-stage, Chronic renal failure syndrome, NOS, Chronic Renal Failure, Chronic Renal Disease, Chronic Kidney Failure
French INSUFFISANCE RENALE CHRONIQUE, Défaillance rénale terminale, Insuffisance rénale chronique au stade ultime (IRSU), Insuffisance rénale chronique, Défaillance rénale chronique
Portuguese INSUFICIENCIA RENAL CRONICA, Insuficiência renal de fase terminal, Doença renal de fase terminal, Falência Crônica do Rim, Insuficiência renal crónica, ESRD, Doença Renal Terminal, Insuficiência Renal Terminal, Nefropatia Terminal, Falência Crônica Renal, Falência Renal Crônica
Spanish INSUFICIENCIA RENAL CRONICA, Fallo renal terminal, Fallo renal crónico, Enfermedad renal terminal (ERT), RINON, INSUFICIENCIA CRONICA, Fallo Crónico del Riñón, Fracaso Renal Crónico, enfermedad renal terminal, insuficiencia renal en estadio terminal (trastorno), insuficiencia renal en estadio terminal, Insuficiencia renal crónica, NFF, Enfermedad Renal Terminal, Insuficiencia Renal Terminal, Nefropatía Terminal, Fallo Crónico Renal, Fallo Renal Crónico
Dutch nierfalen chronisch, terminaal nierfalen, terminale nierziekte, aandoening; nier, terminaal, aandoening; renaal, terminaal, Chronische nierinsufficiëntie, niet gespecificeerd, Terminale nierziekte, chronisch nierfalen, Nierfalen, chronisch, Nierfalen, eindstadium-, Nierziekte, eindstadium-, Chronische nierinsufficiëntie, Insufficiëntie, chronische nier-, Nierinsufficiëntie, chronische, Renale insufficiëntie, chronische
German chronisches Nierenversagen, terminales Nierenversagen, terminale Nierenerkrankung (ESRD), Chronische Niereninsuffizienz, nicht naeher bezeichnet, Chronische Niereninsuffizienz, NIERENVERSAGEN CHRONISCH, RENALES VERSAGEN CHRONIC, Terminale Niereninsuffizienz, Nierenversagen chronisch, ESRD, Nierenkrankheit, Endstadium, Nierenversagen, chronisches, Renales Versagen, Endstadium, Renales Versagen, chronisches, Terminale Nierenerkrankung, Chronisches Nierenversagen
Italian Insufficienza renale in stadio terminale, Nefropatia in stadio terminale, ESRD, Malattia del rene allo stadio terminale, Insufficienza renale allo stadio terminale, Malattia renale allo stadio terminale, Insufficienza renale cronica
Japanese 末期腎不全, 末期腎疾患(ESRD), マンセイジンフゼン, マッキジンシッカンESRD, マッキジンフゼン, 腎不全-慢性, 腎機能不全-慢性, 慢性腎不全, 慢性腎機能不全, 腎不全末期, 腎臓疾患末期, 腎不全-末期, 腎臓疾患-末期
Swedish Njursvikt, kronisk
Czech chronická renální insuficience, Konečné stadium renálního onemocnění, Chronické selhání ledvin, Chronické renální selhání, chronické selhání ledvin, ledviny - selhání chronické, Chronic Kidney Disease, CKD
Finnish Krooninen munuaisten vajaatoiminta
Russian POCHECHNAIA NEDOSTATOCHNOST' FUNKTSIONAL'NAIA, KHRONICHESKAIA, ПОЧЕЧНАЯ НЕДОСТАТОЧНОСТЬ ФУНКЦИОНАЛЬНАЯ, ХРОНИЧЕСКАЯ
Korean 상세불명의 만성 콩팥(신장)기능상실, 만성 콩팥(신장)기능상실, 말기 콩팥(신장)병
Croatian BUBREŽNA INSUFICIJENCIJA, KRONIČNA
Polish Schyłkowa niewydolność nerek, Niewydolność nerek przewlekła krańcowa, Niewydolność nerek przewlekła całkowita, Przewlekła nieodwracalna niewydolność nerek, Niewydolność nerek schyłkowa
Hungarian Chronikus veseelégtelenség, chronikus veseelégtelenség, végstádiumú veseelégtelenség, végstádiumú vesebetegség (ESRD)
Norwegian Kronisk nyresvikt, ESRD

Ontology: Chronic kidney disease stage 5 (C2316810)

Definition (NCI) Long-standing and persistent renal disease with glomerular filtration rate (GFR) less than 15 ml/min.
Definition (NCI_FDA) Chronic, irreversible renal failure.
Concepts Disease or Syndrome (T047)
ICD10 N18.6 , N18.5
SnomedCT 433146000
LNC LP128701-2, LP135358-2, MTHU040642
English End Stage Kidney Disease, End Stage Kidney Failure, End Stage Renal Failure, chronic kidney disease stage 5 (diagnosis), chronic kidney disease stage 5, Chronic kidney disease stage 5 (disorder), chronic kidney disease, stage 5, Chronic Kidney Disease, Stage 5, End Stage Renal Disease, Chronic kidney disease stage 5, End stage renal disease, CKD stage 5, Chronic kidney disease, stage 5, End-Stage Renal Disease, End-stage renal disease, RENAL DISEASE, END STAGE, END STAGE RENAL DISEASE (ESRD), DISEASE (ESRD), END STAGE RENAL, RENAL DISEASE (ESRD), END STAGE, ESRD, END STAGE RENAL DISEASE, ESRD
Spanish enfermedad renal crónica, estadio 5 (trastorno), enfermedad renal crónica estadio 5, enfermedad renal crónica estadio 5 (trastorno), enfermedad renal crónica, estadio 5