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

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 m^2.3 A full list of indications for referral is provided in Table 1.³

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

Dialysis

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