ADDITIONAL CONSIDERATIONS

It is essential that renally cleared medications be dosed based on eGFR. Furthermore, drugs that may precipitate an acute decline in renal function, such as nonsteroidal antiinflammatory drugs should be avoided. Careful consideration must be given when administering iodinated contrast due to the risk of acute renal failure. In addition, gadolinium-based contrast should be used judiciously in patients with stage 4 or 5 CKD because of the increased risk of nephrogenic systemic fibrosis.

END-STAGE RENAL DISEASE

Ultimately, a small proportion of patients with CKD will progress to end-stage renal disease (ESRD), defined as the need for dialysis therapy or kidney transplantation. The rate of progression, however, is highly variable across patients.

Dialysis is typically initiated when the eGFR falls below 10 mL/min/1.73 m²; however, there are numerous acute indications as well, which include refractory hyperkalemia, volume overload, and uremia.

In most patients, preemptive kidney transplantation is preferred over ongoing dialysis because the long-term survival is significantly better. Compared with dialysis patients on the transplant list, patients who receive a kidney transplant have an initial increase in mortality; however, at 4 months post-transplant the risk of death is equal between the two groups, and thereafter transplanted patients have a 68% lower risk of mortality compared with patients on dialysis. The survival benefit is particularly robust among patients with diabetes.