Renal/Urology · PANCE / PANRE

End-Stage Renal Disease and Dialysis

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

Stage 5 CKD (eGFR <15) requiring renal replacement therapy or kidney transplant.

Also known as: ESRD, ESKD, kidney failure, dialysis, hemodialysis, peritoneal dialysis

Overview

Permanent loss of kidney function requiring renal replacement therapy (RRT) — hemodialysis (HD), peritoneal dialysis (PD), or kidney transplantation — to sustain life. Generally corresponds to eGFR <15 mL/min/1.73 m² (CKD stage G5) with uremic symptoms or complications.

Epidemiology

Over 800,000 Americans live with ESRD. Diabetes (~45%) and hypertension (~30%) are the dominant causes. Black patients have nearly 4× the incidence of white patients.

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Question 1RenalMedium
A 65-year-old male with CKD stage 4 (eGFR 18, declining 4 mL/min/year) is referred for nephrology evaluation. His 45-year-old son is willing to donate a kidney. Which of the following best describes when transplant evaluation should ideally begin?
  • AWhen eGFR is at or below 20 mL/min
  • BWhen eGFR is below 15 mL/min
  • CWhen eGFR is below 10 mL/min
  • DAfter dialysis is initiated
Reveal answer & full explanation
Correct answer: A — When eGFR is at or below 20 mL/min
  • AWhen eGFR is at or below 20 mL/min✓
  • BWhen eGFR is below 15 mL/min
  • CWhen eGFR is below 10 mL/min
  • DAfter dialysis is initiated

Why eGFR at or below 20 mL/min is correct

  • Pre-emptive kidney transplantation (transplant before dialysis) yields the best outcomes: better graft and patient survival, lower delayed graft function, and avoidance of dialysis morbidity
  • UNOS listing criteria allow referral when eGFR is at or below 20 mL/min/1.73m²
  • Evaluation should start early — workup takes 3-6 months, and living donor workup takes 6-12 months

Why the others are wrong

  • B) When eGFR is below 15 mL/min — waiting until eGFR is below 15 risks the patient beginning dialysis before transplant evaluation and workup are complete
  • C) When eGFR is below 10 mL/min — too late; pre-emptive transplant opportunity is likely lost
  • D) After dialysis is initiated — post-dialysis transplant has significantly worse outcomes compared to pre-emptive transplant

Additional high-yield points

  • Living donor kidney has significantly better outcomes than deceased donor: 12-year graft survival 85% vs 55%
  • Age 65 is not a contraindication to transplant — functional status and comorbidities matter more than chronological age
Question 2RenalMedium
A 50-year-old male with stage 5 chronic kidney disease (CKD) (eGFR 8) on peritoneal dialysis (PD) develops fever, cloudy PD effluent, and abdominal pain. PD effluent WBC count is 420 cells/mm3 (85% polymorphonuclear leukocytes (PMNs)). Gram stain shows gram-positive cocci in clusters. PD peritonitis is diagnosed. Which of the following is the most appropriate initial treatment?
  • AIntraperitoneal vancomycin plus ceftazidime
  • BImmediate catheter removal
  • COral ciprofloxacin
  • DIV vancomycin plus ceftazidime
Reveal answer & full explanation
Correct answer: A — Intraperitoneal vancomycin plus ceftazidime
  • AIntraperitoneal vancomycin plus ceftazidime✓
  • BImmediate catheter removal
  • COral ciprofloxacin
  • DIV vancomycin plus ceftazidime

Why Intraperitoneal vancomycin plus ceftazidime is correct

  • Peritoneal dialysis (PD) peritonitis is the most common serious complication of peritoneal dialysis
  • Diagnosis requires: cloudy effluent PLUS PD WBC above 100 cells/mm3 (above 50% polymorphonuclear leukocytes (PMNs)) PLUS organisms on Gram stain or culture
  • Intraperitoneal (IP) antibiotics are preferred over IV because they achieve higher drug concentrations at the infection site
  • Empiric coverage: IP vancomycin (gram-positive coverage, including Staph) plus IP ceftazidime (gram-negative coverage)
  • Antibiotics are adjusted once culture results return

Why the others are wrong

  • B) Immediate catheter removal — catheter removal is reserved for fungal peritonitis, refractory bacterial peritonitis at 48-72 hours, or fecal organisms (which suggest bowel perforation); this patient's initial presentation calls for antibiotic therapy first
  • C) Oral ciprofloxacin — oral antibiotics do not achieve adequate intraperitoneal concentrations; IP delivery is the preferred route
  • D) IV vancomycin plus ceftazidime — IV administration provides lower peritoneal drug levels than IP dosing; IP is the preferred route for PD peritonitis

Additional high-yield points

  • Most common organisms: gram-positive cocci — Staph epidermidis (most common, from touch contamination); Staph aureus (more severe, associated with catheter exit-site infection)
  • Gram stain showing gram-positive cocci in clusters points to Staphylococcus, supporting empiric vancomycin selection
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Risk factors

  • Diabetic and hypertensive nephropathy (combined >70%)
  • Glomerulonephritis, PKD, recurrent AKI, obstructive uropathy
  • Non-adherence with ACEi/ARB or BP control
  • Late nephrology referral (eGFR <30 without prior care)
  • Cardiovascular disease, age >65

Pathophysiology

Loss of >90% of nephrons impairs solute clearance, fluid balance, acid-base regulation, and endocrine functions (EPO, calcitriol). Retained uremic toxins (urea, creatinine, beta-2 microglobulin, indoxyl sulfate, p-cresyl sulfate) drive multisystem dysfunction including pericarditis, encephalopathy, platelet defects, and immune impairment.

Clinical presentation

Symptoms

  • Fatigue, weakness, anorexia, nausea, vomiting
  • Pruritus, restless legs, muscle cramps, sleep disturbance
  • Dyspnea from volume overload or anemia
  • Cognitive slowing, confusion, seizures (uremic encephalopathy)
  • Easy bruising or bleeding (uremic platelet dysfunction)

Signs / physical exam

  • Volume overload: edema, elevated JVP, crackles, hypertension
  • Sallow uremic complexion, uremic frost (rare in modern era)
  • Pericardial friction rub (uremic pericarditis — RRT indication)
  • Asterixis, myoclonus in advanced uremia
  • AV fistula thrill/bruit on physical exam in established HD patients

Classic findings

Uremic fetor (urine-like breath odor), uremic frost on skin, and pericardial rub are late findings demanding urgent dialysis initiation.

Differential diagnosis

  • Acute on chronic kidney disease — Superimposed acute insult — volume depletion, nephrotoxin, obstruction; potentially reversible
  • Advanced CKD without indication for RRT — eGFR <15 but asymptomatic, normal electrolytes/volume; continue conservative management
  • Hepatorenal syndrome — Advanced cirrhosis with progressive AKI unresponsive to volume; bridge to transplant
  • Cardiorenal syndrome — Heart failure with renal hypoperfusion; ultrafiltration may be needed but underlying cardiac issue drives course

Diagnostic workup

Diagnostic criteria

RRT indications (AEIOU): refractory Acidosis, Electrolyte disturbance (especially hyperkalemia), Ingestion of dialyzable toxin, Overload (refractory pulmonary edema), Uremia (pericarditis, encephalopathy, bleeding). Asymptomatic eGFR <6 is also commonly an indication.

Labs

  • Serum creatinine, BUN, electrolytes (especially K, HCO3, Ca, phosphate)
  • CBC (normocytic anemia of CKD), iron studies
  • Intact PTH, 25-OH vitamin D
  • Albumin (nutritional marker), lipid panel
  • Hepatitis B surface antibody status (vaccinate if non-immune)

Imaging

  • Renal ultrasound — small echogenic kidneys (or large in PKD, diabetes, amyloid)
  • Echocardiogram pre-RRT and annually — high CVD burden
  • Vascular mapping ultrasound for AV access planning

Diagnostic algorithm

ModalityScheduleAccessProsCons
In-center HD3-4 h, 3×/wkAV fistula/graftSupervised, no home equipmentTravel, hemodynamic shifts, schedule
Home HDDaily/nocturnalAV fistula/graftBetter BP and outcomes, flexibilityTraining burden, partner required
CAPD (PD)4 exchanges/dayPD catheterIndependence, residual functionPeritonitis risk, manual exchanges
APD (PD)Overnight cyclerPD catheterDaytime freeEquipment dependent
TransplantN/AN/ABest survival, quality of lifeSurgical risk, immunosuppression, rejection
Renal replacement therapy modality comparison. Choice individualized to patient lifestyle, comorbidities, and access.

Treatment

First-line

  • Multidisciplinary CKD clinic and modality education starting at eGFR <30
  • Vascular access: AV fistula preferred (created 6+ months before HD start); AV graft if poor vessels; tunneled catheter only for urgent start
  • Hemodialysis — typically 3-4 h sessions × 3/week in-center; nocturnal or home HD options available
  • Peritoneal dialysis — continuous ambulatory (CAPD) or automated (APD) using PD catheter; preserves residual renal function
  • Kidney transplantation — best long-term survival; living donor preferred; preemptive transplant ideal

Second-line / adjunct

  • ESA — epoetin alfa, darbepoetin alfa — target Hb 10-11.5
  • Iron — IV ferric gluconate, iron sucrose, ferric carboxymaltose — most HD patients require IV iron
  • Phosphate binders — sevelamer, lanthanum, calcium acetate, ferric citrate, sucroferric oxyhydroxide — with meals
  • Active vitamin D — calcitriol, paricalcitol, doxercalciferol
  • Calcimimetics — cinacalcet (oral), etelcalcetide (IV) — for secondary hyperparathyroidism
  • Conservative (non-dialytic) management — for frail or terminal patients prioritizing quality of life over longevity

Complications

  • Cardiovascular disease (leading cause of death, ~50%)
  • Access complications: thrombosis, infection, steal syndrome, aneurysm
  • Peritonitis (PD), exit-site infection, catheter malfunction
  • CKD-MBD: vascular calcification, calciphylaxis, fractures
  • Dialysis-related amyloidosis (β2-microglobulin) — carpal tunnel, arthropathy
  • Hypotension during HD, disequilibrium syndrome at initiation
  • Depression, cognitive impairment, sexual dysfunction

PANCE pearls

  • Avoid placing PIVs, blood draws, or BP cuffs on the AV fistula arm — preserve access.
  • Hyperkalemia in ESRD: emergent dialysis if EKG changes or K >6.5 not responsive to medical management.
  • Calciphylaxis: painful violaceous skin lesions, often on adipose areas; sodium thiosulfate, lower phosphate, normalize calcium-phosphate product.
  • PD peritonitis: cloudy effluent with WBC >100 (>50% PMN); empiric intraperitoneal cefazolin + ceftazidime (or vancomycin if MRSA risk).
  • Kidney transplant doubles life expectancy vs HD and is more cost-effective; refer early — even before dialysis (preemptive).

References

  • KDIGO 2024 — KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
  • USRDS 2023 — United States Renal Data System Annual Data Report 2023
  • KDOQI 2020 — KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update (AJKD 2020)
  • ISPD 2022 — ISPD Peritonitis Recommendations: 2022 Update on Prevention and Treatment

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Related Renal/Urology diagnoses

Acute Kidney Injury (AKI)Chronic Kidney Disease (CKD)Nephrotic SyndromeNephritic SyndromeIgA NephropathyAcute Tubular Necrosis (ATN)Acute Interstitial Nephritis (AIN)Post-Streptococcal Glomerulonephritis (PSGN)Autosomal Dominant Polycystic Kidney Disease (ADPKD)Urolithiasis (Kidney Stones)Acute Cystitis (Uncomplicated UTI)Acute PyelonephritisRenal Cell Carcinoma (RCC)Bladder Cancer

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.