From the Research
Hemodialysis in chronic kidney disease (CKD) is typically initiated when kidney function declines to the point where conservative management is no longer sufficient to maintain health and quality of life, with the main indications including severe symptoms of uremia, fluid overload, dangerous electrolyte imbalances, and a glomerular filtration rate (GFR) below 15 mL/min/1.73 m², as suggested by the most recent study 1.
The decision to start hemodialysis is complex and influenced by many factors, including the patient's symptoms, signs, and overall health status. According to the latest guidelines, early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m2) is not associated with a morbidity and mortality benefit, as shown in the Initiating Dialysis Early and Late (IDEAL) study 2.
Some key points to consider when deciding to initiate hemodialysis include:
- Severe symptoms of uremia, such as nausea, vomiting, fatigue, and cognitive impairment
- Fluid overload that doesn't respond to diuretics
- Dangerous electrolyte imbalances, particularly hyperkalemia
- A glomerular filtration rate (GFR) below 15 mL/min/1.73 m²
- The presence of diabetes or rapidly declining kidney function, which may necessitate earlier initiation of dialysis
While hemodialysis is life-saving for many CKD patients, it can lead to several complications, including:
- Common cardiovascular issues, such as hypotension during dialysis, arrhythmias, and long-term increased risk of heart disease
- Access-related problems, such as infection or thrombosis of arteriovenous fistulas or grafts
- Infections, particularly bloodstream infections, due to repeated vascular access
- Electrolyte imbalances, especially if fluid removal is too rapid, leading to disequilibrium syndrome
- Anemia, which often worsens or persists despite treatment due to blood loss during dialysis and reduced erythropoietin production
- Other complications, such as muscle cramps, headaches, and a long-term risk of amyloidosis
Regular monitoring and proactive management of these potential complications are crucial for optimizing outcomes in hemodialysis patients, as emphasized in a study on the estimation, measurement, and relevance of the glomerular filtration rate in stage 5 chronic kidney disease 3. Additionally, a study on stage 5-CKD under nephrology care highlights the need for further research on the efficacy of non-dialysis treatment in stage 5-CKD patients 4.
Overall, the decision to initiate hemodialysis should be based on a comprehensive assessment of the patient's symptoms, signs, and overall health status, rather than solely on estimated GFR, as suggested by a review on chronic kidney disease diagnosis and management 5.