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Am Fam Physician. 2021;104(5):493-499

Patient information: See related handout on advanced kidney disease.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

End-stage renal disease (ESRD) is diagnosed when kidney function is no longer adequate for long-term survival without kidney transplantation or dialysis. Primary care clinicians should refer people at risk of ESRD to nephrology to optimize disease management. Kidney transplantation typically yields the best patient outcomes, although most patients are treated with dialysis. The decision to initiate dialysis is best made through shared decision-making. Because most patients with ESRD elect to receive hemodialysis, the preservation of peripheral veins is important for those with stage III to V chronic kidney disease. A palliative approach to ESRD is a reasonable alternative to dialysis, particularly for individuals with limited life expectancy, with severe comorbid conditions, or who wish to avoid medical interventions. For patients with ESRD, vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus (through 26 years of age), and Streptococcus pneumoniae is advised. Routine cancer screening for patients not receiving kidney transplantation is discouraged. Controlling blood pressure in patients receiving dialysis improves mortality. Volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment in these patients. Insulin is the preferred treatment for patients with ESRD and diabetes mellitus requiring medication. Patients should be monitored for signs of protein-energy wasting and malnutrition. Clinicians must be aware of the many medical complications associated with ESRD.

End-stage renal disease (ESRD) is when kidney function is no longer adequate for long-term survival without kidney transplantation or dialysis.1,2 The estimated glomerular filtration rate (GFR) is usually less than 15 mL per minute per 1.73 m2 when this occurs.3 Kidney failure, a more concise term, may soon replace ESRD.4

RecommendationSponsoring organization
Do not perform routine cancer screening in asymptomatic patients receiving dialysis if they have a limited life expectancy.American Society of Nephrology
Do not place peripherally inserted central catheters in patients with stage III to V chronic kidney disease without consulting nephrology.American Society of Nephrology
Do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.American Society of Nephrology

The incidence of ESRD increased more than threefold between 1980 and 2000 because of increasing numbers of patients with diabetes mellitus, hypertension, and related conditions. Although this increase has leveled off, the prevalence of ESRD has steadily increased, largely because of longer patient survival. By 2018, there were more than 750,000 individuals with ESRD in the United States. The disease is costly, accounting for approximately 10% of Medicare fee-for-service spending. It is also associated with high mortality; fewer than one-half of those who initiate hemodialysis survive for five years.5

Primary care clinicians play a key role in diagnosing chronic kidney disease, monitoring its progression, treating modifiable risk factors, and identifying and treating complications. The evaluation of chronic kidney disease was discussed in a previous issue of American Family Physician (AFP).6 ESRD often develops slowly and can be prevented in many cases. This article provides an overview of the medical management of ESRD, as well as its comorbidities and complications.

Nephrology Referral

Early nephrology referral for patients at increased risk of ESRD is vital because it is associated with improved patient-centered outcomes, including mortality.3,7 Approximately one-third of all patients receive little to no nephrology care before ESRD is diagnosed.5,8

Patients with chronic kidney disease should be referred to nephrology if their estimated GFR falls below 30 mL per minute per 1.73 m2.3 A full list of indications for referral is provided in Table 1.3

Abrupt, sustained decrease in estimated GFR
Estimated GFR < 30 mL per minute per 1.73 m2
Hereditary kidney disease
Persistent significant albuminuria (albumin-to-creatinine ratio 300 mg per g [≥ 30 mg per mmol] or albumin excretion rate ≥300 mg per 24 hours)
Persistent hypokalemia or hyperkalemia
Progression of chronic kidney disease (progressive decline in estimated GFR, particularly if decline is > 5 mL per minute per 1.73 m2 per year)
Recurrent or extensive nephrolithiasis
Resistant hypertension
Risk of end-stage renal disease within one year is 10% to 20% or higher as determined by a validated risk prediction tool, such as the Kidney Failure Risk Calculator (
Urinary red cell casts or persistent red blood cells > 20 per high power field (if otherwise unexplained)

Goals of early referral include initiating disease-specific therapies; slowing the progression of chronic kidney disease; evaluating and treating comorbid conditions and complications; providing psychosocial support; and planning for kidney transplantation, dialysis, or conservative kidney management.3 Multidisciplinary care, involving primary care and other clinicians, pharmacists, nurses, dietitians, and social workers, may improve patient outcomes.9

Kidney Transplantation

A key consideration for patients with ESRD is establishing eligibility for kidney transplantation, which, compared with dialysis or conservative management, improves survival and quality of life.10 Referral to a transplantation program is advised when estimated GFR falls below 30 mL per minute per 1.73 m2 because receiving a transplant before dialysis is needed improves survival.11 Early referral allows time for medical and psychosocial evaluation, treatment of modifiable risk factors, and identification of a living donor; it also maximizes accrual of wait time on the transplant waiting list.10 The median wait time for a transplant is four years, and currently only 5% of patients who initiate dialysis were preemptively placed on the kidney transplant waiting list.5


Most patients elect to receive dialysis to treat their ESRD,5 and these patients tend to live longer than those choosing conservative management.12 Yet, because of the time commitment, discomfort, and complications associated with dialysis, shared decision-making should be used, with adequate time for patients to consider the various dialysis modalities and the option of conservative management.3 Many patients do not receive adequate education before starting dialysis, and one survey showed that 61% of patients who chose dialysis later regretted the decision.8

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