eGFR under 15 mL/min/1.73m²

KDIGO's Table 2 names an eGFR under 15 "Kidney failure," and a practice point spells the threshold out inline, "kidney failure (estimated glomerular filtration rate [eGFR] <15 ml/min per 1.73 m2)." There is no separate definition sentence in the guideline; the row is the definition. It is also the edge of what the guideline covers: KDIGO states that it "is not intended for people receiving dialysis nor those who have a kidney transplant," so what follows is what it says for the interval before either.

A number is not a start date. The most important thing KDIGO says about this band is that dialysis does not begin because the eGFR crossed 15. Practice Point 5.4.1: "Initiate dialysis based on a composite assessment of a person's symptoms, signs, QoL, preferences, level of GFR, and laboratory abnormalities." Practice Point 5.4.2 lists the situations that do call for it, symptoms or signs attributable to kidney failure such as uremic neurological signs, pericarditis, anorexia, intractable itching, or electrolyte and acid-base abnormalities that resist treatment; inability to control fluid or blood pressure; and nutritional or cognitive decline despite intervention, and adds that "This often but not invariably occurs in the GFR range between 5 and 10 ml/min per 1.73 m2." The guideline cites the IDEAL trial, which showed "no survival advantage to early start dialysis," and concludes that people "need to be treated according to symptoms and signs, not simply based on laboratory values."

What should already be in motion. KDIGO's planning point applies at a GFR "<15–20," so by this band it expects vascular access referral or transplant evaluation to be under way; it calls an eGFR of 15 "acceptable to use for initiating vascular access referral." It asks that people be informed about every option for kidney replacement therapy and about comprehensive conservative care, and that conservative management be supported "for people who choose not to pursue KRT." Monitoring is four or more times a year at every albuminuria level. Uremic symptoms are assessed at each visit with a validated tool, malnutrition is screened twice a year, and the complications of G4 (anemia, high potassium, bone mineral disorder, acidosis) are managed by the team.

Medicines at this stage. KDIGO keeps the ACE inhibitor or ARB going below an eGFR of 30, and the one stage-specific exception it gives is here: consider reducing the dose or stopping "to reduce uremic symptoms while treating kidney failure." An SGLT2 inhibitor already started may be continued below 20 unless dialysis begins. The guideline notes that statin benefit shrinks as eGFR falls, "with little evidence of benefit in people on dialysis." Every kidney-cleared drug needs its dose reconsidered, gadolinium contrast is restricted to the safer agent groups, and NSAIDs are avoided.