Dialysis Initiation in Chronic Kidney Disease
Dialysis should be initiated when patients reach CKD stage 5 (GFR <15 mL/min/1.73 m²), with specific clinical considerations potentially prompting earlier initiation in some cases. 1
CKD Staging and Progression to Dialysis
- CKD is classified into five stages based on glomerular filtration rate (GFR), with decreasing values indicating progressive loss of kidney function 2
- Stage 1: GFR ≥90 mL/min/1.73 m² with evidence of kidney damage 2
- Stage 2: GFR 60-89 mL/min/1.73 m² with evidence of kidney damage 2
- Stage 3: GFR 30-59 mL/min/1.73 m², moderate decrease in kidney function 2
- Stage 4: GFR 15-29 mL/min/1.73 m², severe decrease in kidney function 2
- Stage 5: GFR <15 mL/min/1.73 m² or dialysis, indicating kidney failure 2
When to Start Dialysis
- Dialysis should be considered when patients reach CKD stage 5 (GFR <15 mL/min/1.73 m²) 1
- The decision to initiate dialysis should be based on a combination of GFR estimation and clinical assessment, not solely on GFR values 1, 3
- Early dialysis initiation (at GFR >10 mL/min/1.73 m²) has not shown mortality or morbidity benefits according to recent evidence 3
- In asymptomatic patients with stage 5 CKD, dialysis may be safely delayed until GFR is as low as 5-7 mL/min/1.73 m² with careful clinical follow-up 3
Clinical Indications for Dialysis Initiation
- Uremic complications that may prompt dialysis initiation include: 1
- Malnutrition despite dietary intervention
- Fluid overload unresponsive to diuretics
- Bleeding due to uremic platelet dysfunction
- Uremic serositis (pericarditis, pleuritis)
- Depression and cognitive impairment
- Peripheral neuropathy
- Electrolyte abnormalities (hyperkalemia, metabolic acidosis)
Preparation for Dialysis
- Patients who reach CKD stage 4 (GFR <30 mL/min/1.73 m²) should receive timely education about kidney failure treatment options 1
- Education should cover kidney transplantation, peritoneal dialysis, hemodialysis (home or in-center), and conservative management 1
- Predialysis education helps patients make informed decisions and has been associated with improved outcomes including delayed dialysis initiation, fewer cardiovascular complications, and reduced mortality 4
- Patients with CKD stages 4-5 should be referred to nephrology for specialized care 5
Special Considerations
- Decision-making is more complex for older and more fragile patients, requiring careful weighing of risks and benefits 1, 3
- Conservative therapy without dialysis may be appropriate for some patients, particularly those with multiple comorbidities or frailty 1
- For patients choosing conservative management, care should focus on maximizing quality of life through dietary and pharmacological therapy to minimize uremic symptoms 1
- The cardiovascular risk associated with dialysis is 10-20 times higher than in the general population, which should be considered in the decision-making process 6
Accurate Assessment of Kidney Function
- GFR should be estimated using validated equations or by measurement of creatinine and urea clearances, not simply by serum creatinine and urea nitrogen levels 1
- Creatinine-based formulas to estimate GFR become less accurate in advanced CKD, which is why clinical assessment becomes increasingly important 3
- In patients with unusual creatinine generation (very muscular or malnourished), GFR should be estimated using methods independent of creatinine generation 1