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 uremic symptoms develop
BWhen eGFR is below 10 mL/min
CWhen eGFR is at or below 20 mL/min
DAfter dialysis is initiated
EWhen eGFR is below 15 mL/min
Reveal answer & full explanation
Correct answer: C — When eGFR is at or below 20 mL/min
AWhen uremic symptoms develop
BWhen eGFR is below 10 mL/min
CWhen eGFR is at or below 20 mL/min✓
DAfter dialysis is initiated
EWhen eGFR is below 15 mL/min
Why When eGFR is 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
KDIGO 2020 advises referral for transplant evaluation at least 6-12 months before anticipated dialysis (with transplant education once eGFR falls below 30), and under OPTN policy deceased-donor waiting time begins to accrue once 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
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
When eGFR is below 10 mL/min — too late; pre-emptive transplant opportunity is likely lost
After dialysis is initiated — post-dialysis transplant has significantly worse outcomes compared to pre-emptive transplant
When uremic symptoms develop — tempting because dialysis initiation is timed to uremic symptoms rather than a specific eGFR, but transplant evaluation must start well before uremia so the recipient and living-donor workups are finished in time for a pre-emptive transplant
Additional high-yield points
Living donor kidneys have significantly better outcomes than deceased donor kidneys: 10-year all-cause graft survival is roughly 60-65% versus about 45-55%
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?
AOral ciprofloxacin
BIV vancomycin plus ceftazidime
COral linezolid plus oral ciprofloxacin
DImmediate catheter removal
EIntraperitoneal vancomycin plus ceftazidime
Reveal answer & full explanation
Correct answer: E — Intraperitoneal vancomycin plus ceftazidime
AOral ciprofloxacin
BIV vancomycin plus ceftazidime
COral linezolid plus oral ciprofloxacin
DImmediate catheter removal
EIntraperitoneal 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 at least 2 of 3 (ISPD 2022): abdominal pain and/or cloudy effluent; effluent WBC above 100/uL with above 50% PMNs after a dwell of at least 2 hours; positive effluent 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
Immediate catheter removal — catheter removal is reserved for fungal peritonitis, refractory peritonitis (effluent that has not cleared after 5 days of appropriate antibiotics), or fecal organisms (which suggest bowel perforation); this patient's initial presentation calls for antibiotic therapy first
Oral ciprofloxacin — ciprofloxacin gives unreliable coverage of the staphylococci suggested by this Gram stain, and a single oral agent does not provide the dual gram-positive and gram-negative empiric coverage required; IP delivery is the preferred route
IV vancomycin plus ceftazidime — IV administration provides lower peritoneal drug levels than IP dosing; IP is the preferred route for PD peritonitis
Oral linezolid plus oral ciprofloxacin — pairs a gram-positive agent with a gram-negative agent, so it looks like complete empiric coverage, but intraperitoneal dosing is the preferred route for empiric PD peritonitis therapy because it reaches far higher peritoneal drug levels than oral dosing, and linezolid is held for resistant gram-positive organisms such as vancomycin-resistant enterococci
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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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). Phosphate retention and loss of renal 1α-hydroxylation lower calcitriol and calcium, driving secondary hyperparathyroidism and renal osteodystrophy (CKD-MBD); loss of EPO production causes a hypoproliferative normocytic anemia (low reticulocyte count). Retained uremic toxins (urea, creatinine, beta-2 microglobulin, indoxyl sulfate, p-cresyl sulfate) drive multisystem dysfunction including pericarditis, encephalopathy, platelet defects, and immune impairment.
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 antibiotics covering gram-positives (vancomycin or cefazolin, chosen by center; vancomycin if MRSA risk) and gram-negatives (ceftazidime or an aminoglycoside).
Kidney transplant doubles life expectancy vs HD and is more cost-effective; refer early — transplant education once eGFR <30 and referral for evaluation at least 6-12 months before expected dialysis (KDIGO 2020); deceased-donor waiting time accrues from eGFR ≤20 (OPTN), so preemptive listing is possible.
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
KDIGO 2020 — KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation (Transplantation 2020;104(4S1):S11-S103)
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