From the Guidelines
Hemodialysis in chronic kidney disease (CKD) is typically initiated when the glomerular filtration rate (GFR) falls below 15 mL/min/1.73 m² or when severe symptoms of uremia develop, as recommended by the most recent guidelines 1. The decision to start hemodialysis is based on a comprehensive assessment of the patient's overall health, including the presence of symptoms such as refractory fluid overload, hyperkalemia (potassium >6.5 mEq/L) unresponsive to medical management, metabolic acidosis, and uremic symptoms like pericarditis, encephalopathy, or severe nausea and vomiting. Some patients may start dialysis earlier, around a GFR of 20 mL/min/1.73 m², if they have diabetes or rapidly declining kidney function 1.
Indications for Hemodialysis
- Refractory fluid overload
- Hyperkalemia (potassium >6.5 mEq/L) unresponsive to medical management
- Metabolic acidosis
- Uremic symptoms such as pericarditis, encephalopathy, or severe nausea and vomiting
- Diabetes or rapidly declining kidney function, which may require earlier initiation of dialysis around a GFR of 20 mL/min/1.73 m²
Common Complications of Dialysis
- Hypotension during treatment
- Muscle cramps
- Dialysis disequilibrium syndrome
- Vascular access-related issues, such as infection or thrombosis of arteriovenous fistulas or grafts
- Cardiovascular problems like accelerated atherosclerosis and left ventricular hypertrophy
- β2-microglobulin amyloidosis
- Increased risk of infections
- Malnutrition
- Bone disease due to secondary hyperparathyroidism
- Anemia
- Psychological issues, including depression, which can significantly impact quality of life 1
Regular monitoring and proactive management of these complications are essential aspects of care for dialysis patients. The creation and maintenance of a dialysis access is vital for reducing morbidity, mortality, and cost of treatment for end-stage renal disease patients 1. The choice of vascular access should be individualized based on the patient's overall End-Stage Kidney Disease (ESKD) Life-Plan and the corresponding kidney replacement therapy (KRT) modality choice and dialysis access 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
- 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 initiation, as seen in 43.8% of patients in one study 3
- Other indications for HD initiation include hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition 4
Common Complications of Dialysis
- Hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition are common complications of CKD and ESRD that require management 4
- Infection is a risk associated with central venous catheters used for HD, which can be mitigated with proper care and management 4
- Cardiovascular disease is a major complication of CKD, and cardiovascular risk reduction is an important aspect of CKD management 5
- Anemia is a common complication of CKD, affecting 98.6% of patients in one study, and requires management with erythropoiesis-stimulating agents and iron supplementation 3
Preparation for Dialysis
- Predialysis education is important to help patients make informed decisions about their treatment options and to improve outcomes 6
- Referral to a nephrologist in a timely fashion is necessary to allow for adequate pre-dialysis care and planning 2
- Patients should be educated about the different dialysis modalities, including peritoneal dialysis and HD, and the importance of vascular access creation and maintenance 4
- Patients with CKD should be monitored for complications and referred to a nephrologist if they are at high risk of CKD progression 5