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. The decision to initiate hemodialysis should be based on the patient's overall ESKD Life-Plan and the corresponding kidney replacement therapy (KRT) modality choice and dialysis access 1.
Indications for Hemodialysis
The main indications for hemodialysis in CKD patients include:
- A glomerular filtration rate (GFR) below 15 mL/min/1.73 m²
- Severe uremic symptoms (such as nausea, vomiting, fatigue, and cognitive impairment)
- Refractory fluid overload
- Hyperkalemia (potassium >6.5 mEq/L) not responding to medical management
- Severe metabolic acidosis
- Life-threatening complications like pulmonary edema or uremic pericarditis
Common Complications of Dialysis
Complications of hemodialysis can be significant and include both acute and chronic issues, such as:
- Hypotension during dialysis
- Muscle cramps
- Dialysis disequilibrium syndrome
- Infections related to vascular access
- Cardiovascular disease (accelerated atherosclerosis and left ventricular hypertrophy)
- Anemia
- Mineral and bone disorders
- Malnutrition
- Dialysis-related amyloidosis
- Access-related problems, such as thrombosis or infection of arteriovenous fistulas or grafts
- Psychological issues like depression and a reduced quality of life due to the time-consuming nature of dialysis treatments, as noted in the context of individualized patient care 1.
Management of Complications
Regular monitoring and proactive management of these complications are essential for improving outcomes in dialysis patients. This includes careful consideration of the patient's ESKD Life-Plan and the corresponding KRT modality choice and dialysis access, to minimize the risk of complications and optimize quality of life 1.
From the Research
Indications for Hemodialysis (HD) in Chronic Kidney Disease (CKD)
- The decision to initiate dialysis is complex and is influenced by many factors, including ESKD-related symptoms and signs 2
- ESKD-related symptoms and signs are the most common indications for dialysis initiation, rather than solely relying on estimated GFR (eGFR) 2
- Acute pulmonary edema (APE) is one of the most urgent indications for HD, 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, objectified in 98.6% of cases 3
- Hypocalcemia and hyperphosphatemia are also common, noted in 60.8% and 84.9% of cases, respectively 3
- Infection is a risk, particularly with central venous catheters, which are associated with the highest risk of infection 4
- Heart failure and insufficient dialysis dose per week are predictive factors of mortality at the 1st year of HD 3
- C-reactive protein more than 21 mg/L, insufficient dialysis per week, modified Charlson Comorbidity Index less than 6, and APE at the dialysis initiation are predictive factors of three-month mortality 3
Management of Complications
- Controlling blood pressure in patients receiving dialysis improves mortality 5
- Volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment in these patients 5
- Insulin is the preferred treatment for patients with ESRD and diabetes mellitus requiring medication 5
- Patients should be monitored for signs of protein-energy wasting and malnutrition 5