When should dialysis be initiated in a patient with chronic kidney disease and a Glomerular Filtration Rate (GFR) of 9?

When to Initiate Dialysis in CKD with GFR 9

Dialysis should be initiated based primarily on clinical symptoms and complications rather than GFR alone, though at a GFR of 9 mL/min/1.73m², the patient is approaching the threshold where dialysis is typically considered necessary. 1

Decision Framework for Dialysis Initiation

Clinical Indications for Immediate Dialysis Initiation

• Presence of uremic symptoms:
  • Nausea, vomiting, fatigue
  • Uremic encephalopathy
  • Uremic pericarditis
• Volume overload unresponsive to diuretics:
  • Pulmonary edema
  • Severe peripheral edema
  • Refractory hypertension
• Severe electrolyte disorders:
  • Hyperkalemia
  • Severe metabolic acidosis
  • Significant hyponatremia or hypernatremia 1, 2

GFR Considerations

• At GFR 9 mL/min/1.73m², the patient is in the range where dialysis is often initiated:
  • Young/middle-aged adults typically start at 7-9 mL/min/1.73m²
  • Elderly patients typically start at 10-10.5 mL/min/1.73m² 1
• The IDEAL study showed no survival advantage to early dialysis initiation (GFR >10 mL/min/1.73m²) compared to later initiation (GFR 5-7 mL/min/1.73m²) 3

Nutritional Status Assessment

• If protein-energy malnutrition develops or persists despite attempts to optimize nutrition, and there's no other apparent cause, dialysis initiation is recommended 4, 1
• Regular monitoring of nutritional parameters is essential in making this determination

Age-Specific Considerations

Younger Patients (<65 years)

• May safely delay dialysis until GFR falls below 6-9 mL/min/1.73m² if asymptomatic 5
• More likely to benefit from earlier transplantation evaluation

Elderly Patients (≥75 years)

• May benefit from dialysis initiation at GFR 9-12 mL/min/1.73m² 5
• Careful consideration of comorbidities, frailty, and quality of life is essential
• Conservative management may be appropriate for some elderly patients with significant comorbidities 3

Mortality Considerations

• Patients initiating dialysis primarily due to volume overload have a 1.69 times higher risk of mortality compared to those starting due to laboratory evidence of kidney function decline 6
• At GFR <6 mL/min/1.73m², dialysis initiation is associated with higher median life expectancy of 26,25, and 19 months for patients aged 65,75, and 85 years, respectively 5
• The 5-year survival rate after dialysis initiation is approximately 40% 2

Practical Approach

1. Assess for uremic symptoms and complications
2. Evaluate volume status and electrolyte balance
3. Monitor nutritional parameters
4. Consider patient's age, comorbidities, and preferences
5. If GFR is 9 mL/min/1.73m² and the patient is symptomatic, initiate dialysis
6. If asymptomatic, consider:
   • For younger patients: Close monitoring with potential to delay until GFR 5-7 mL/min/1.73m²
   • For elderly patients: Consider initiating dialysis, especially with comorbidities

Important Caveats

• Creatinine-based eGFR formulas are less accurate at very low GFR levels 3
• Shared decision-making between physician, patient, and family is crucial 3
• Regular monitoring (every 1-2 weeks) is essential if delaying dialysis in a patient with GFR 9 mL/min/1.73m²
• Delaying dialysis in symptomatic patients can increase morbidity and mortality 1

Remember that while GFR is an important parameter, the clinical presentation and symptoms should guide the decision to initiate dialysis, especially at a GFR of 9 mL/min/1.73m².