From the Guidelines
Hemodialysis in chronic kidney disease (CKD) should be initiated when patients develop severe uremic symptoms or when certain laboratory abnormalities occur, with the main indications including uremic symptoms, fluid overload, hyperkalemia, metabolic acidosis, and an estimated glomerular filtration rate (eGFR) below 15 mL/min/1.73m², as recommended by guidelines 1. The decision to initiate hemodialysis therapy is influenced by individual factors, such as dialysis accessibility, transplantation option, and patient compliance with diet and medications, and should be based on a compromise designed to maximize patient quality of life (QOL) by extending the dialysis-free period while avoiding complications that will decrease the length and quality of dialysis-assisted life 1. Some of the key indications for hemodialysis in CKD include:
- Uremic symptoms such as nausea, vomiting, and altered mental status
- Fluid overload unresponsive to diuretics
- Hyperkalemia (potassium > 6.5 mEq/L) refractory to medical management
- Metabolic acidosis (bicarbonate < 15 mEq/L)
- An estimated glomerular filtration rate (eGFR) below 15 mL/min/1.73m² Urgent dialysis may be needed for severe hyperkalemia, pulmonary edema, or uremic pericarditis. Complications of dialysis can be both acute and chronic, and include:
- Hypotension during dialysis
- Muscle cramps
- Dialysis disequilibrium syndrome
- Access-related issues such as infection or thrombosis of arteriovenous fistulas or grafts
- Cardiovascular disease
- Anemia requiring erythropoietin therapy
- Secondary hyperparathyroidism
- Amyloidosis
- Infections due to frequent hospital exposures and compromised immune systems
- Malnutrition and decreased quality of life Regular monitoring and management of these potential complications are essential for optimal patient care in those undergoing chronic hemodialysis, as recommended by guidelines 1.
From the Research
Indications for Hemodialysis (HD) in Chronic Kidney Disease (CKD)
- The decision to initiate dialysis is based on the presence of symptoms and signs of end-stage kidney disease, rather than solely on estimated glomerular filtration rate (eGFR) 2
- Acute pulmonary edema (APE) is one of the most urgent indications for HD initiation, as seen in 43.8% of patients in a study 3
- Other indications for HD include hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition 4
Common Complications of Dialysis
- Anemia is a common complication of dialysis, affecting 98.6% of patients in a study 3
- Hypocalcemia and hyperphosphatemia are also common, affecting 60.8% and 84.9% of patients, respectively 3
- Infection is a risk associated with central venous catheters used for HD, with the highest risk of infection compared to arteriovenous fistula or graft 4
- Heart failure and insufficient dialysis dose per week are predictive factors of mortality at the 1st year of HD 3
Timing of Dialysis Initiation
- Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m2) is not associated with a morbidity and mortality benefit 2
- 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, with careful clinical follow-up and adequate patient education 2
- The decision on when to start dialysis should be a shared decision between physician, patients, and family members, and should be tailored to the individual patient's needs 2