From the Guidelines
The decision to initiate dialysis should be based on a comprehensive evaluation of the patient's kidney function, overall health status, and quality of life considerations, and generally, dialysis is initiated when GFR falls below 15 mL/min/1.73m² with symptoms, or when there are life-threatening complications like severe hyperkalemia, metabolic acidosis, or volume overload that cannot be managed with medications 1. To determine if a patient needs dialysis, several clinical factors must be considered, including:
- Glomerular filtration rate (GFR)
- Blood urea nitrogen (BUN) and creatinine levels
- Electrolyte imbalances
- Fluid overload
- Uremic symptoms The timing of dialysis initiation is crucial and should be individualized, taking into account the patient's goals, life preferences, prognosis, and expected benefits and burdens associated with kidney failure and its treatment 1. A nephrologist should make the decision to start dialysis after a thorough evaluation of the patient's condition, considering the latest clinical practice guidelines, such as those from the American Journal of Kidney Diseases 1. It is essential to note that the purpose of dialysis is not solely to prolong life but to promote living, and the decision to initiate or forgo dialysis should be a shared decision-making process among patients, their families, caregivers, and physicians 1.
From the Research
Patient Requirements for Dialysis
The decision to initiate dialysis in a patient is complex and depends on various factors, including the presence of end-stage kidney disease (ESKD)-related symptoms and signs 2.
- The estimated glomerular filtration rate (eGFR) is not the sole indicator for dialysis initiation, as creatinine-based formulae can be inaccurate in patients with ESKD 2.
- Early dialysis initiation (eGFR > 10 mL/min/1.73 m2) does not provide a morbidity and mortality benefit, as shown in the Initiating Dialysis Early and Late (IDEAL) study 2.
- In asymptomatic patients with stage 5 chronic kidney disease, dialysis may be safely delayed until the eGFR is at least as low as 5-7 mL/min/1.73 m2, provided there is careful clinical follow-up and adequate patient education 2.
Electrolyte and Fluid Management
Electrolyte and fluid management is crucial in patients undergoing dialysis, as the kidney's regulatory functions are compromised 3.
- The fluid status of patients on hemodialysis (HD) and peritoneal dialysis (PD) must be carefully monitored, and electrolyte imbalances must be corrected to prevent complications 3.
- Serum electrolyte patterns can vary in patients with end-stage renal disease (ESRD), and hyperchloremia can be present in a significant proportion of patients 4.
Individualized Approach
The management of patients with kidney disease requires an individualized approach, taking into account the patient's symptoms, signs, and overall health status 5, 2.
- Patients with chronic kidney disease (CKD) and urolithiasis may require surgical or non-invasive management, and the selection of the appropriate strategy can result in good outcomes and minimal complications 5.
- The decision to initiate dialysis should be a shared decision between the physician, patient, and family members, and should be tailored to the individual patient's needs 2.