From the Guidelines
Hemodialysis is indicated in patients with Chronic Kidney Disease (CKD) who are preparing to initiate hemodialysis, transitioning from another kidney replacement modality, or are already on hemodialysis with a failing arteriovenous access or hemodialysis catheter, as part of their individualized End-Stage Kidney Disease (ESKD) Life-Plan 1. The decision to initiate hemodialysis is based on the patient's overall ESKD Life-Plan and the corresponding kidney replacement therapy modality choice.
- The main considerations for hemodialysis include the patient's current kidney function, symptoms, and overall health status.
- Common complications of dialysis can be significant and include both acute and chronic issues, such as:
- Acute complications: hypotension, muscle cramps, dialysis disequilibrium syndrome, and access-related problems.
- Chronic complications: cardiovascular disease, β2-microglobulin amyloidosis, renal osteodystrophy, and increased infection risk.
- Regular monitoring and proactive management of these potential complications are crucial for optimizing patient outcomes on hemodialysis, with a focus on minimizing morbidity, mortality, and improving quality of life 1.
- It is essential to consider the patient's individualized ESKD Life-Plan when making decisions about hemodialysis vascular access, rather than making decisions in isolation or independent of the patient's overall plan.
- The patient's current individualized ESKD Life-Plan and the corresponding kidney replacement therapy modality choice should guide the decision to initiate hemodialysis, as stated in the kdoqi clinical practice guideline for vascular access: 2019 update 1.
From the Research
Indications for Hemodialysis (HD) in Chronic Kidney Disease (CKD)
- The decision to initiate hemodialysis is complex and influenced by various factors, including symptoms and signs of end-stage kidney disease (ESKD) 2
- ESKD-related symptoms, such as acute pulmonary edema, are common indications for dialysis initiation 3
- Creatinine-based formulae to estimate glomerular filtration rate (GFR) are inaccurate in patients with ESKD, and the decision to start dialysis should not be based solely on estimated GFR (eGFR) 2
- Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m2) is not associated with a morbidity and mortality benefit 2
Common Complications of Dialysis
- Anemia, hypocalcemia, and hyperphosphatemia are common complications in patients initiating hemodialysis 3
- Heart failure and insufficient dialysis dose per week are predictive factors of mortality at the 1st year of HD 3
- Infection, particularly with central venous catheters, is a significant risk for patients undergoing hemodialysis 4
- Cardiovascular disease, including heart failure and arrhythmias, is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD) 5
Timing of Dialysis Initiation
- In asymptomatic patients with stage 5 chronic kidney disease, dialysis may be safely delayed until the eGFR is at least as low as 5-7 mL/min/1.73 m2 if there is careful clinical follow-up and adequate patient education 2
- The decision on when to start dialysis is even more challenging in older patients, and conservative care should be considered in appropriate cases 2
- Timely referral to a nephrologist is essential to allow adequate pre-dialysis care and planning 2