Disease Trajectories Before ESRD: Implications for Clinical Management

One of the biggest challenges nephrologists face is to predict complex clinical pathways of kidney disease progression that do not follow a steady linear decline. This unpredictability often becomes a barrier to timely shared decision making between patients and physicians and could lead to adverse patient outcomes. By using numerous analytic approaches to characterize the longitudinal changes in kidney function, emerging evidence has disclosed the heterogeneous trajectories of kidney disease progression, particularly in late-stage chronic kidney disease (CKD) nearing end-stage renal disease (ESRD), and showed their independent associations with various clinical outcomes. These findings, in turn, have reinforced the importance of incorporating individual kidney disease trajectories into the clinical management of patients with late-stage CKD, which may help clarify the optimal timing of preparatory interventions, such as vascular access planning and transplant referral, and deliver better care with potential downstream benefits, such as a lower incidence of ESRD or a more seamless transition to ESRD. In this article, we review the current evidence on trajectories of kidney disease progression, particularly among patients with late-stage CKD progressing to ESRD, and discuss their implications for clinical management.