Introduction

Chronic kidney disease (CKD) is a progressive and irreversible condition that eventually leads to end-stage renal disease (ESRD). At this stage, renal replacement therapy—either dialysis or kidney transplantation—becomes essential for patient survival. Among these options, kidney transplantation offers superior long-term survival, better quality of life, and lower healthcare costs compared to dialysis.

One of the most important parameters for determining transplant eligibility is the estimated glomerular filtration rate (eGFR).

 

Stages of CKD and eGFR Thresholds

CKD Stage

eGFR (ml/min/1.73m²)

Clinical Status

Stage 1

≥ 90

Kidney damage with normal function

Stage 2

60–89

Mild loss of function

Stage 3a

45–59

Mild to moderate loss

Stage 3b

30–44

Moderate to severe loss

Stage 4

15–29

Severe loss of kidney function

Stage 5

< 15

ESRD – Requires dialysis or transplant

 

When to Refer for Kidney Transplantation?

eGFR ≤ 20 ml/min/1.73m²

Patients should be referred for transplant evaluation at this stage.

Early referral allows time for:

HLA typing and cross-matching.

Infectious disease screening.

Cardiovascular risk assessment.

Donor identification.

eGFR ≤ 15 ml/min/1.73m²

This is the definition of ESRD.

The patient becomes a definite transplant candidate even if not yet on dialysis.

Preemptive Kidney Transplant (Before Dialysis)

If eGFR falls below 15 but dialysis has not started, the patient is still eligible and strongly encouraged for transplantation.

Preemptive transplantation is associated with:

Better graft survival.

Lower risk of cardiovascular disease.

Avoidance of dialysis-related complications.

Improved quality of life.

 

What If the Patient Has eGFR = 12 but Is Not on Dialysis?

This patient is already in Stage 5 CKD (ESRD).

Even without dialysis, he/she is a clear candidate for kidney transplant.

Dialysis is only started if the patient develops:

Severe uremic symptoms (nausea, vomiting, anorexia, pruritus, mental confusion).

Life-threatening metabolic derangements (hyperkalemia, severe acidosis, fluid overload, pericarditis).

Thus, transplant listing should not be delayed just because dialysis has not started.

 

Key Clinical Message

Transplant evaluation begins when eGFR < 20.

Patient is a definite candidate when eGFR < 15, regardless of dialysis status.

Preemptive transplantation is the gold standard whenever possible