From the Guidelines
Hemodialysis is indicated in patients with Chronic Kidney Disease (CKD) who have developed end-stage renal disease (ESRD) or severe complications of kidney failure, and the decision for hemodialysis vascular access should be based on the patient’s individualized End-Stage Kidney Disease (ESKD) Life-Plan 1. The main indications for hemodialysis in CKD include:
- A glomerular filtration rate (GFR) below 15 mL/min/1.73m²
- Severe uremic symptoms (such as nausea, vomiting, and confusion)
- Refractory fluid overload
- Hyperkalemia (potassium >6.5 mEq/L) unresponsive to medical management
- Metabolic acidosis Dialysis may also be considered earlier if there's rapid decline in kidney function or persistent symptoms despite optimal medical therapy. Common complications of hemodialysis can be significant and include both acute and chronic issues, such as:
- Hypotension during dialysis
- Muscle cramps
- Dialysis disequilibrium syndrome
- Access-related problems such as infection or thrombosis of arteriovenous fistulas or grafts
- Long-term complications including cardiovascular disease (accelerated atherosclerosis and left ventricular hypertrophy), amyloidosis, and malnutrition Patients on hemodialysis are also at increased risk for infections and may experience anemia, bone disease, and electrolyte imbalances, highlighting the need for regular monitoring and proactive management of these potential complications 1. Key considerations in the management of patients on hemodialysis include the creation of a personalized ESKD Life-Plan, which takes into account the patient’s preferences, comorbidities, and lifestyle, to ensure optimal care and minimize complications 1.
From the Research
Indications for Hemodialysis (HD) in Chronic Kidney Disease (CKD)
- The decision to initiate HD is complex and influenced by many factors, including ESKD-related symptoms and signs 2
- Common indications for dialysis initiation include acute pulmonary edema (APE), hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition 3, 4
- The presence of estimated GFR <15 mL/min/1.7 3m(2) is often used as an endpoint, but this definition is still a surrogate since many patients may live years without being symptomatic or needing dialysis 5
- Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m2) is not associated with a morbidity and mortality benefit, and dialysis may be safely delayed until the eGFR is at least as low as 5-7 mL/min/1.73 m2 in asymptomatic patients with stage 5 CKD 2
Common Complications of Dialysis
- Hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition are common complications of CKD that require management 4, 6
- Infection is a common complication of HD, particularly in patients with central venous catheters 4
- Cardiovascular disease is a major cause of morbidity and mortality in patients with CKD, and cardiovascular risk reduction is an important part of CKD management 6
- Patients on HD are also at risk of developing other complications, such as hypocalcemia and hyperphosphatemia 3