From the Guidelines
Hemodialysis in chronic kidney disease (CKD) should be initiated when patients experience severe symptoms of uremia, have refractory fluid overload, or when certain laboratory values indicate critical kidney dysfunction, with a recommended initiation at an estimated glomerular filtration rate (eGFR) of approximately 10 mL/min/1.73 m2, as suggested by theoretical considerations 1. The decision to start hemodialysis is complex and depends on various individual factors, including dialysis accessibility, transplantation option, peritoneal dialysis eligibility, home dialysis eligibility, vascular access, age, declining health, fluid balance, and compliance with diet and medications 1.
Indications for Hemodialysis
- Severe symptoms of uremia
- Refractory fluid overload
- Laboratory values indicating critical kidney dysfunction, such as:
- Serum creatinine above 6-8 mg/dL
- eGFR below 15 mL/min/1.73m²
- Severe hyperkalemia (potassium >6.5 mEq/L) unresponsive to medical management
- Metabolic acidosis
- Uremic symptoms such as pericarditis, encephalopathy, or intractable nausea and vomiting
Complications of Dialysis
- Acute complications:
- Hypotension during dialysis
- Muscle cramps
- Dialysis disequilibrium syndrome
- Access site problems such as infection or thrombosis
- Long-term complications:
- Cardiovascular disease
- Amyloidosis
- Bone disease
- Malnutrition
- Infection remains a significant risk, particularly related to vascular access, and patients may also experience psychological issues and reduced quality of life due to the time-consuming nature of dialysis treatments 1. Regular monitoring and proactive management of these potential complications are essential for optimal patient care in hemodialysis. It is also important to consider the patient’s current individualized End-Stage Kidney Disease (ESKD) Life-Plan and the corresponding kidney replacement therapy (KRT) modality choice and dialysis access when deciding on hemodialysis vascular access 1.
From the FDA Drug Label
- INDICATIONS AND USAGE Sevelamer hydrochloride tablets are indicated for the control of serum phosphorus in patients with chronic kidney disease (CKD) on dialysis. The indications for Hemodialysis (HD) in Chronic Kidney Disease (CKD) are not directly stated in the provided drug label.
- The label only mentions that sevelamer hydrochloride tablets are indicated for the control of serum phosphorus in patients with CKD who are on dialysis.
- Common complications of dialysis are not mentioned in the provided text 2.
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 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) 3
- 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 3
- Acute pulmonary edema (APE) is one of the most urgent indications for HD initiation, accounting for 43.8% of patients 4
- Other indications for HD initiation include hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition 5
Common Complications of Dialysis
- Cardiovascular disease, including heart failure and arrhythmias, is a major complication of dialysis 6
- Anemia is a common complication of CKD, affecting 98.6% of patients at HD initiation 4
- Hyperphosphatemia and hypocalcemia are also common complications of CKD, affecting 84.9% and 60.8% of patients at HD initiation, respectively 4
- Infection is a risk of dialysis, particularly with central venous catheters 5
- Malnutrition is a common complication of CKD, and patients require monitoring for protein-calorie malnutrition 7
Timing of Dialysis Initiation
- The decision to start dialysis should be based on a shared decision between physician, patient, and family members, and should be tailored to the individual patient's needs 3
- Asymptomatic patients with stage 5 CKD may be able to safely delay dialysis initiation until the eGFR is at least as low as 5-7 mL/min/1.73 m2, with careful clinical follow-up and adequate patient education 3
- Older patients with comorbidities and frailty may require careful consideration of the risks and benefits of dialysis initiation, and conservative care may be an appropriate option in some cases 3