When is dialysis indicated in patients with impaired renal function?

From the Guidelines

Dialysis is indicated in patients with impaired renal function when they develop symptoms or signs attributable to kidney failure, inability to control volume status or blood pressure, or progressive deterioration in nutritional status, as recommended by the KDIGO 2024 clinical practice guideline 1. The decision to initiate dialysis should be based on a composite assessment of a person's symptoms, signs, quality of life (QoL), preferences, level of glomerular filtration rate (GFR), and laboratory abnormalities. Some key considerations for initiating dialysis include:

• Symptoms or signs attributable to kidney failure, such as neurological signs and symptoms attributable to uremia, pericarditis, anorexia, medically resistant acid-based or electrolyte abnormalities, intractable pruritus, serositis, and acid-base or electrolyte abnormalities
• Inability to control volume status or blood pressure
• Progressive deterioration in nutritional status refractory to dietary intervention, or cognitive impairment It is also important to consider planning for preemptive kidney transplantation and/or dialysis access in adults when the GFR is <15–20 ml/min per 1.73 m2 or risk of kidney replacement therapy (KRT) is >40% over 2 years, as suggested by the KDIGO 2024 guideline 1. The IDEAL Study, a clinical trial that informed the KDOQI guideline, found no significant difference in time to death, cardiovascular or infectious events, or complications of dialysis between patients who started dialysis earlier (at a higher GFR) and those who started later (at a lower GFR) 1. Therefore, the initiation of dialysis should be individualized based on the patient's overall clinical condition, rather than solely on laboratory values, and should take into account the patient's symptoms, QoL, and preferences. Early nephrology consultation is essential to prepare for potential renal replacement therapy and to discuss options including hemodialysis, peritoneal dialysis, or kidney transplantation.

From the Research

Indications for Dialysis

The decision to initiate dialysis in patients with impaired renal function is based on several factors, including:

• Electrolyte and acid-base disturbances, such as hyperkalemia, metabolic acidosis, hypocalcemia, and hyperphosphatemia 2
• Blood urea nitrogen (BUN) level, with a level of 75 mg/dL being a useful indicator for dialysis in asymptomatic patients 3
• Clinical condition and prognosis of the patient, including the trajectory of disease and the presence of complications such as congestive heart failure (CHF) and pulmonary edema 3, 4
• Absolute and relative indicators, such as the rate of decline in renal function and the presence of symptoms such as nausea, vomiting, and fatigue 3

Specific Conditions Requiring Dialysis

Dialysis may be indicated in the following conditions:

• Acute kidney injury (AKI) with severe electrolyte and acid-base disturbances 2
• End-stage renal disease (ESRD) with hyperkalemia and volume overload 4
• Renal infarction with acute kidney injury (AKI) and decreased estimated glomerular filtration rate (eGFR) 5
• Fluid and electrolyte problems, such as hypervolemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and metabolic acidosis, that are not responsive to medical management 6

Timing and Modality of Dialysis

The timing and modality of dialysis depend on the individual patient's needs and clinical scenario:

• Early initiation of renal replacement therapy (RRT) may be associated with decreased mortality in patients with AKI 3
• Continuous dialysis techniques may be useful in patients with severe electrolyte and acid-base disturbances 2
• The choice of dialysis modality, such as hemodialysis or peritoneal dialysis, depends on the patient's clinical condition, lifestyle, and personal preferences 4