Chronic kidney disease (CKD) is a condition where the kidneys are damaged and cannot filter blood effectively. There are 5 stages of CKD based on the glomerular filtration rate (GFR), which measures how well the kidneys are filtering waste from the blood.
Stages of CKD
The 5 stages of CKD are:
- Stage 1 – GFR 90+ ml/min (normal or high)
- Stage 2 – GFR 60-89 ml/min (mildly decreased)
- Stage 3 – GFR 30-59 ml/min (moderately decreased)
- Stage 4 – GFR 15-29 ml/min (severely decreased)
- Stage 5 – GFR
Stage 5 CKD, also known as end stage renal disease (ESRD), is the most severe stage where the kidneys are functioning at less than 15% of normal capacity. At this stage, waste products build up to dangerous levels in the body, leading to symptoms like nausea, weakness, and shortness of breath. Without treatment, stage 5 CKD can be fatal.
Treatment Options for Stage 5 CKD
The main treatment options for stage 5 CKD are:
- Dialysis – A treatment that filters waste and excess fluid from the blood using a machine when the kidneys can no longer perform this function adequately. There are two types of dialysis – hemodialysis and peritoneal dialysis.
- Kidney transplant – Replacing the diseased kidneys with a healthy donated kidney. This is the optimal treatment to resume normal kidney function, but organ availability is limited.
- Conservative management – Controlling symptoms through diet, medication and fluid intake, without dialysis or transplant. This is typically for older patients with limited life expectancy.
Are all Stage 5 CKD Patients on Dialysis?
Not all stage 5 CKD patients require or are on dialysis. Some key points:
- Dialysis is required when the kidneys fail and are no longer able to filter blood adequately. However, the need for dialysis depends on various factors like kidney function, symptoms, and overall health condition.
- Some stage 5 CKD patients may choose not to undergo dialysis if they are elderly, have other life-limiting illnesses, or do not want this intensive treatment. They may opt for conservative management instead.
- Patients with kidney failure who are on the waitlist for a kidney transplant may not need long-term dialysis if they are able to get a donor kidney within a few months.
- A small number of patients have very slow CKD progression and remain stable even with stage 5. They may delay dialysis for months or even years.
That said, the vast majority of patients with stage 5 CKD will eventually require renal replacement therapy in the form of dialysis or kidney transplant. But dialysis initiation depends on individual factors, so not every single stage 5 patient is necessarily on dialysis.
Dialysis Initiation in Stage 5 CKD
The decision of when to start dialysis for stage 5 CKD patients is made based on a combination of factors:
- Estimated GFR – Dialysis is generally initiated between GFR levels of 5-10ml/min.
- Symptoms – Intolerable symptoms like fatigue, nausea, difficulty breathing, fluid overload point to the need for dialysis.
- Nutritional status – Worsening malnutrition indicates impaired kidney function requiring dialysis.
- Fluid overload – Excess fluid that does not respond to diuretics or fluid restriction requires removal by dialysis.
- Metabolic changes – Electrolyte abnormalities and acidosis that do not respond to supplements and medications warrant beginning dialysis.
- Comorbidities – Coexisting heart disease, diabetes or other conditions may necessitate earlier dialysis initiation.
- Quality of life – Severely reduced physical functioning and health-related quality of life are strong indicators for dialysis.
Doctors monitor stage 5 CKD patients closely through lab work, fluid status, weight changes and symptoms to determine the optimal time for dialysis initiation. This allows dialysis to begin before the patient has adverse events.
Statistics on Dialysis Usage in Stage 5 CKD
Several studies looking at stage 5 CKD patient populations give an idea of the proportion receiving dialysis:
- A Canadian study published in Nephrology Dialysis Transplantation found 86% of patients with stage 5 CKD were receiving dialysis. 14% used conservative management.
- Data from the United States Renal Data System indicates approximately 70% of stage 5 CKD patients undergo hemodialysis or peritoneal dialysis 3 months after diagnosis.
- A study in Clinicoecon Outcomes Res found 95% of patients starting dialysis had an estimated GFR less than 15 ml/min, indicating stage 5 CKD.
- According to the National Institute of Diabetes and Digestive and Kidney Diseases, about 2 in 3 people with stage 5 CKD receive dialysis to treat kidney failure.
Based on these data, a significant majority, but not all stage 5 CKD patients, undergo dialysis treatment. A small percentage are managed conservatively without dialysis.
Reasons Some Stage 5 CKD Patients May Not Get Dialysis
There are a few key reasons why some stage 5 CKD patients may not get dialysis treatment:
- Rapid disease progression – In some cases, CKD progresses so rapidly that patients die from complications before dialysis is initiated.
- Dementia or mental impairment – Patients with severe dementia may not understand or cooperate with dialysis treatment and are often managed supportively.
- Advanced age and frailty – Elderly, frail patients with multiple comorbidities have reduced life expectancy, so conservative care may be preferred.
- Limited physical access – Lack of vascular access or other anatomical barriers may prevent undergoing hemodialysis.
- Advanced second disease – End-stage cancer, advanced heart failure or other life-limiting disease may influence choice of conservative management.
- Personal preference – Some patients decline dialysis after being informed of risks and benefits, desiring quality of life over quantity.
However, most patients who reach stage 5 CKD remain on dialysis for the rest of their lives or until they can get a kidney transplant. Discussing all options thoroughly with patients is important when making dialysis decisions.
Outcomes for Stage 5 CKD Patients on Dialysis
Stage 5 CKD patients on dialysis experience the following outcomes:
- The mortality rate is high – around 20% per year. 5-year survival is approximately 35%.
- Cardiovascular disease is the leading cause of death.
- Hospitalization rates are elevated due to infections, cardiovascular events, and complications of kidney disease.
- Many patients have reduced quality of life and impaired physical function.
- Malnutrition and protein energy wasting are common concerns.
- Anemia requiring erythropoiesis-stimulating agents and iron supplementation is frequent.
- Blood pressure medications, phosphate binders, and fluid restriction are commonly required.
Dialysis improves outcomes and prolongs survival compared to conservative care. But patients still face shortened lifespans, a high symptom burden, and reduced quality of life.
Mortality Rates for Dialysis Patients with Stage 5 CKD
| Study | Patient Population | Mortality Rate |
|---|---|---|
| US Renal Data System 2019 | Stage 5 CKD patients on dialysis | 20.9% annually |
| BMJ Open 2015 | Incident dialysis patients | 34.5% at 1 year |
| NDT Plus 2010 | Elderly dialysis patients | 45% at 1 year |
| Advances in Chronic Kidney Disease 2010 | Stage 5 CKD patients starting dialysis | 44% over 4 years |
As shown, mortality rates in the first year of dialysis for stage 5 CKD patients range from 20-45% based on study population. This demonstrates the substantially increased risk of death associated with end stage kidney disease.
Conclusion
In summary, while a majority of stage 5 CKD patients develop end stage renal disease necessitating dialysis, not every single individual requires or receives dialysis. Factors like patient preference, rapid progression, and limited life expectancy allow some to be conservatively managed. However, most patients will eventually need dialysis as kidney function declines. Dialysis initiation depends on estimated GFR, symptoms, fluid status, metabolic factors, and quality of life. Although dialysis sustains life, stage 5 CKD patients on dialysis continue to face high morbidity and mortality. Ongoing research on optimizing the timing and delivery of dialysis aims to improve long-term outcomes in this seriously ill population.