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Draft: not yet reviewed by a clinician

Use this page to prepare questions for your care team. It does not replace their advice. Your own targets and doses come from your nephrologist, diabetes team and renal dietitian.

Stage G5 without dialysis

In short

G5 means your eGFR is under 15. This is kidney failure, but it does not mean dialysis starts tomorrow. Dialysis is started because of symptoms or problems, not because of one number; that often happens when eGFR is between 5 and 10 (KDIGO 2024, practice points 5.4.1–5.4.2). Watch for the symptoms below and report them. Some people choose comprehensive conservative care instead of dialysis; that is a real choice with active care, not "doing nothing" (KDIGO 2024, practice point 5.5.2). With type 1 diabetes, insulin is always needed, whatever you choose.

Your numbers

Starting points, not your prescription

These numbers are typical starting points from guidelines. Your nephrologist, diabetes team and renal dietitian set your own numbers from your blood tests, urine output and medicines, and change them as your labs change. If your lab report or your team says something different, they win.

Starting numbers at G5 without dialysis (70 kg adult with type 1 diabetes; the same as the app's "Suggest targets"):

Protein Potassium Phosphorus Sodium Fluid Energy
0.8 g/kg (about 56 g) review ceiling 2,500 mg, only if your blood potassium is high 900 mg under 2,000 mg ask your team; a limit may be set if you pass less urine or swell 30 kcal/kg (about 2,100 kcal)

Tests to expect

Test How often
Calcium and phosphate every 1–3 months
PTH every 3–6 months
Hemoglobin and iron about every 3 months
Check for undernutrition (weight, appetite) twice a year
Potassium, bicarbonate, eGFR often; your team sets the timing

Sources: KDIGO 2017 (recommendation 3.1.2); KDIGO 2026 anemia; KDIGO 2024 (practice point 5.2.3.2); fluid (AKF).

When dialysis is started

KDIGO lists these reasons to start dialysis (KDIGO 2024, practice point 5.4.2 and Table 41), in plain words:

  • Symptoms from kidney failure, such as trouble thinking, poor appetite, itching that will not stop, inflammation around the heart (pericarditis) or other body linings, or acid and salt problems that medicines cannot fix.
  • Fluid or blood pressure that cannot be controlled.
  • Nutrition that keeps getting worse even with diet help, or a decline in thinking.

The decision weighs your symptoms, your quality of life, what you want, your eGFR and your blood tests together (practice point 5.4.1).

Symptoms to report

Tell your team about these at every visit, or sooner if they are new or getting worse (KDIGO 2024, practice point 5.2.2.1):

  • poor appetite or nausea
  • tiredness or feeling washed out
  • itching
  • trouble thinking clearly
  • breathlessness or swelling
  • weight loss you did not plan

Comprehensive conservative care

Comprehensive conservative care is planned, whole-person care for kidney failure without dialysis. It includes slowing kidney damage, active treatment of symptoms, shared decisions, advance care planning, and psychological, social, family and spiritual support (KDIGO 2015 supportive care). It also treats problems such as anemia, and what you eat and drink may help you feel better (NIDDK). People who want to focus on quality of life may choose it, especially those who are frail or have other serious illnesses (NIDDK). KDIGO asks for advance care planning support for people who choose it (KDIGO 2024, practice point 5.5.3). See Advance care planning.

Type 1 diabetes at G5

  • Insulin is always needed. Insulin is the treatment for type 1 diabetes at every stage (ADA 2026 §9, recommendation 9.1). Without enough insulin, ketones build up and diabetic ketoacidosis (DKA) can follow, especially with missed doses or illness (ADA: DKA; 2024 consensus). This does not change if you choose conservative care.
  • Lows are more likely. Insulin needs fall as eGFR falls, and a poor appetite adds to the risk (JBDS–Renal Association; ADA–KDIGO 2022). Your team adjusts your insulin plan; tell them when you are eating less.
  • Goals may relax. Less strict glucose goals may be right when the risk of lows outweighs the benefit. Every plan should still avoid lows and highs that make you feel unwell (ADA 2026 §6, recommendation 6.5).
  • A1c is unreliable now (KDIGO 2022, practice point 2.1.2). CGM data are more useful.

What to do

  • Write down your symptoms each week (appetite, nausea, itch, sleep, breathlessness, swelling) and bring the list to your visits.
  • Weigh yourself at the same time each day if your team asks, and report sudden gains.
  • Decide with your team, and the people close to you, which path you prefer: dialysis, transplant, or comprehensive conservative care.
  • Name a health care proxy and write down your wishes (Advance care planning).
  • If dialysis is likely, make sure your access is planned or ready (Dialysis access).
  • Never stop basal insulin, even when you are not eating. Call your diabetes team for a plan.
  • Keep glucose tablets by your bed and in your bag; check glucagon is in date.
  • If your appetite is poor, ask for a renal dietitian (KDIGO 2024, practice point 5.2.3.3).
  • Set your stage to 5 in the app: phosphorus becomes 900 mg and potassium 2,500 mg (Targets and warnings).

Examples

A poor-appetite day. You can only manage half your usual breakfast. Treat any low straight away. Tell your diabetes team that you are eating less, so they can adjust your plan. Small, frequent meals with some fat and starch give energy without much potassium or phosphorus: a slice of white toast has about 35 mg potassium and 28 mg phosphorus, and a tablespoon of olive oil has none (USDA). A dietitian can tailor this (Eating enough).

"My eGFR is 9. Do I need dialysis now?" Not because of the number alone. Your team looks at your symptoms, fluid, blood tests and wishes (KDIGO 2024, practice point 5.4.1).

Ask your care team

  1. Which symptoms should make me call you before my next visit?
  2. Is my access ready if I choose dialysis? How long would it take?
  3. What would comprehensive conservative care look like for me, and who would be my team?
  4. How should my insulin plan change when I eat less?
  5. Should my glucose goals change now?
  6. Do I need a fluid limit, and how much urine am I still making?

Get help now if…

Call 911 (or your local emergency number)

Chest pain (it can be pericarditis); severe breathlessness or not being able to lie flat; new confusion, a seizure or drowsiness you cannot wake from; fainting or a very slow or irregular pulse; a low the person cannot treat themselves (give glucagon, then call); possible DKA: blood ketones of 3.0 mmol/L or more, or any ketones with vomiting, deep fast breathing or fruity breath. With kidney failure, DKA can come with lower ketone readings, so these signs count even under 3.0 (2024 consensus). Full list: Get help now.

Call your care team today

New or worse swelling, much less urine, weight gain above your team's alarm number, vomiting or not eating, or new trouble thinking clearly (KDIGO 2024, Table 41). A lab potassium of 6.0–6.4 mmol/L: KDIGO advises a repeat test within 24 hours, or checks and treatment in hospital now if you feel unwell (KDIGO 2024, Table 28).

Sources

Not yet reviewed by a clinician. Facts and sources last checked 2026-10-06.