AKT · Renal & urology/CKD, RRT & cysticlow yield

End-stage renal disease & renal replacement therapy

CKD G5 (eGFR <15) — kidney function inadequate for life without dialysis or transplant

Overview

Established kidney failure (CKD stage G5, eGFR <15) where renal function is insufficient to sustain life without renal replacement therapy. The three RRT options are haemodialysis, peritoneal dialysis and transplantation (the best outcomes, when suitable); conservative (supportive) care is appropriate for some. The high-yield exam points are dialysis indications, access, and transplant immunosuppression/complications.

Recognise

Uraemic symptoms (nausea, anorexia, pruritus, fatigue, restless legs, encephalopathy), fluid overload, and the metabolic complications of advanced CKD
Dialysis: haemodialysis (AV fistula preferred access — listen for a bruit/thrill; avoid BP/venepuncture in that arm) or peritoneal dialysis (peritonitis risk — cloudy bags)
Transplant: best survival/quality of life; lifelong immunosuppression (tacrolimus/ciclosporin + mycophenolate + steroid)

Red flags

Refractory hyperkalaemia/acidosis/fluid overload or uraemic pericarditis/encephalopathy → urgent dialysis (AEIOU)
Transplant: acute rejection (rising creatinine, tenderness), or infection/malignancy from immunosuppression; PD peritonitis (cloudy effluent, abdominal pain)

Differentials & how to tell them apart

Reversible AKI-on-CKDa treatable acute insult on background CKD — exclude before committing to RRT

Transplant rejection vs calcineurin toxicity vs infectionthe differential for a rising creatinine in a transplant — needs levels/biopsy

PD peritonitiscloudy bag + abdominal pain — intraperitoneal antibiotics

Investigations

eGFR/U&Es, the full CKD complication panel; dialysis adequacy and access surveillance; transplant work-up (HLA/crossmatch, virology, fitness); for a transplant patient with rising creatinine — drug levels, ultrasound/biopsy (rejection vs calcineurin toxicity vs infection).

Management

Renal replacement therapy — transplant (best), haemodialysis or peritoneal dialysis; or conservative care

1As CKD reaches G5, plan RRT in advance (access, transplant work-up) or a conservative pathway. Choose modality with the patient.Gate: Refractory hyperkalaemia/acidosis/overload or uraemic pericarditis/encephalopathy (AEIOU) → urgent dialysis; protect a potential fistula arm (no BP cuff/venepuncture).
2Transplant gives the best survival — maintain immunosuppression and watch for rejection, infection and malignancy. For a rising transplant creatinine, distinguish rejection / CNI toxicity / infection with levels and biopsy.

Haemodialysis or peritoneal dialysis — plan access early (AV fistula for HD; protect the non-dominant arm); PD = home-based, peritonitis risk

Kidney transplantation — best outcomes when suitable; lifelong immunosuppression (calcineurin inhibitor + mycophenolate + corticosteroid)

Manage transplant complications — rejection (biopsy-guided immunosuppression), CNI nephrotoxicity (level/dose), increased infection (CMV/PJP prophylaxis) and malignancy (skin/PTLD) risk

Conservative (supportive) care — a valid pathway for frail patients — symptom control without dialysis

Key points

ESRD (eGFR <15) → transplant (best outcomes) vs haemodialysis (fistula — protect that arm) vs peritoneal dialysis (peritonitis = cloudy bag) vs conservative care. Dialyse urgently for AEIOU. Transplant = lifelong immunosuppression with rejection, infection (CMV/PJP) and cancer risk.

Monitor & prognosis

Dialysis adequacy/access, transplant function + drug levels, complication surveillance (infection/malignancy/bone/CV).

Transplant best; dialysis sustains life with significant morbidity; conservative care appropriate for some.

Source: NICE NG203/NG107; renal MDT