From the Guidelines
Before initiating a patient on dialysis, comprehensive screening laboratory work is essential to assess their overall health and identify potential complications. This should include a complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation studies (PT/INR, PTT), hepatitis B and C serology, HIV testing, and blood type determination, as recommended by various guidelines 1. The CBC assesses for anemia, which is common in end-stage renal disease, while the CMP evaluates electrolyte imbalances, particularly potassium, calcium, phosphorus, and bicarbonate levels that require correction before or during dialysis. Renal function tests (BUN, creatinine) establish baseline severity, and albumin levels help assess nutritional status. Coagulation studies are important as anticoagulation is required during hemodialysis. Infectious disease screening protects both the patient and staff, while blood typing is necessary in case transfusion is needed and for potential future transplantation. Additional tests should include parathyroid hormone (PTH) levels to assess bone mineral metabolism, iron studies to evaluate anemia etiology, and a lipid panel since cardiovascular disease is prevalent in dialysis patients, as noted in 1. An electrocardiogram and chest X-ray are also recommended to assess cardiac status and detect any pulmonary abnormalities before beginning treatment, with echocardiograms suggested at the initiation of dialysis, once patients have achieved dry weight, and at 3-yearly intervals thereafter 1. Initiation of dialysis should be based on a composite assessment of the person's symptoms, signs, quality of life, preferences, level of GFR, and laboratory abnormalities, as outlined in the most recent guideline 1. Key considerations include:
- Evaluating cardiovascular disease risk factors, as cardiovascular disease is a major cause of morbidity and mortality in dialysis patients 1
- Assessing for cardiomyopathy, which can be done using echocardiographic testing, and re-evaluating if there is a change in clinical status or consideration for kidney transplant 1
- Considering the patient's quality of life, preferences, and level of GFR when deciding to initiate dialysis, as recommended in the most recent guideline 1. The most recent and highest quality study 1 prioritizes a composite assessment for initiation of dialysis, emphasizing the importance of considering multiple factors beyond just laboratory results.
From the Research
Full Screening Lab Work Needed Before Initiating Someone in Dialysis
- The decision to initiate dialysis is typically based on the patient's glomerular filtration rate (GFR) and the presence of uremia symptoms or fluid management issues 2.
- According to the study by 2, dialysis initiation is justified at GFR levels of 5-9 ml/min/1.73 m(2) if accompanied by uremia symptoms or fluid management issues.
- However, there is no clear consensus on the specific lab work required before initiating dialysis, but it is generally recommended that patients undergo a comprehensive evaluation, including laboratory tests and imaging studies, to assess their overall health and identify any potential complications 3.
- The study by 4 highlights the importance of annual wellness visits and care management before and after dialysis initiation, but does not specifically address the lab work required before initiating dialysis.
- Predialysis education is also crucial in helping patients make informed decisions and prepare for dialysis, and has been associated with improved outcomes such as delayed initiation of dialysis, cardiovascular complications, and mortality 3.
- The following lab work may be considered before initiating dialysis:
- Complete blood count (CBC)
- Blood chemistry tests (e.g. electrolytes, liver function tests)
- Urinalysis
- Imaging studies (e.g. ultrasound, CT scan)
- Other tests as deemed necessary by the patient's healthcare provider 3.