Management of Stage 5 Kidney Disease

Introduction to Vascular Access

The American Journal of Kidney Diseases recommends creating an arteriovenous fistula (AVF) as the preferred permanent access for patients with stage 5 kidney disease, with planning for AVF creation 3-6 months before anticipated need for dialysis, allowing 6-8 weeks for fistula maturation before use, and avoiding subclavian vein catheterization and PICC lines which can cause central venous stenosis 1
For urgent dialysis, the American Journal of Kidney Diseases suggests using tunneled central venous catheters, which should be used for as brief a period as necessary 1

The American Journal of Kidney Diseases recommends maintaining serum phosphorus between 3.5-5.5 mg/dL, restricting dietary phosphorus to 800-1000 mg/day, and initiating phosphate binders if dietary restriction is insufficient, with both calcium-based binders and non-calcium binders (sevelamer) being effective, and limiting elemental calcium from binders to <1500 mg/day 2
The American Journal of Kidney Diseases suggests maintaining corrected total calcium within normal range, preferably toward lower end (8.4-9.5 mg/dL), and monitoring PTH levels every 3 months, considering vitamin D therapy if deficient (25(OH)D levels <30 ng/mL) 2

The American Journal of Kidney Diseases recommends monthly monitoring of phosphorus levels following dietary phosphorus restriction, regular assessment of volume status and symptoms, and weekly monitoring of electrolytes initially 2
For patients with stage 5 kidney disease, the American Journal of Kidney Diseases guidelines suggest initiating urgent hemodialysis if the patient is not voiding, on IV fluids, and shows signs of volume overload or uremic symptoms, or if there is no response to diuretics 3, 4
The decision to initiate dialysis should be based primarily on clinical assessment of signs/symptoms of uremia, evidence of protein-energy wasting, and inability to safely manage metabolic abnormalities or volume overload with medical therapy 4

Patients who reach CKD stage 5 should receive education about kidney failure treatment options, including maintenance hemodialysis, peritoneal dialysis, and kidney transplantation evaluation, and family members and caregivers should be included in this education 3, 5
Conservative management should be considered as an option for certain patients, particularly those with multiple comorbidities or advanced age who may not benefit from dialysis, to avoid increased morbidity and mortality 3, 4
The American Journal of Kidney Diseases guidelines recommend implementing fluid restriction and salt restriction to manage fluid balance in CKD stage 5 patients, and regularly assessing volume status 5

The timing of dialysis initiation should be primarily based on clinical assessment of symptoms and the ability to manage metabolic abnormalities and volume status medically, and delaying dialysis initiation when clinical indications are present can lead to increased morbidity and mortality 3, 4
Excessive ultrafiltration during initial dialysis sessions can cause hemodynamic instability and increased risk of complications, according to the American Journal of Kidney Diseases guidelines 4