What is the protocol for initiating dialysis in a patient with Chronic Kidney Disease (CKD) and Impaired Renal Function?

From the Guidelines

Dialysis should be initiated in patients with Chronic Kidney Disease (CKD) based on a composite assessment of symptoms, signs, quality of life, preferences, level of GFR, and laboratory abnormalities, as recommended by the KDIGO 2024 clinical practice guideline 1. The protocol for initiating dialysis involves a comprehensive evaluation, including laboratory tests and assessment of comorbidities. 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 Vascular access should be established 3-6 months before anticipated dialysis start, with an arteriovenous fistula being the preferred option 1. Pre-dialysis education is essential, covering both hemodialysis and peritoneal dialysis options. For hemodialysis initiation, typical parameters include blood flow rates of 300-400 mL/min, dialysate flow of 500-800 mL/min, and sessions lasting 3-4 hours three times weekly. Anticoagulation with heparin is usually required, with a typical loading dose of 1000-2000 units followed by 500-1000 units/hour. Vital signs should be monitored throughout sessions, with particular attention to blood pressure, as hypotension is common. Dialysis parameters should be adjusted based on the patient's clinical response, with gradual increases in time and efficiency to avoid dialysis disequilibrium syndrome. Early initiation of dialysis before severe symptoms develop leads to better outcomes by preventing complications of advanced uremia such as pericarditis, encephalopathy, and severe metabolic derangements 1.

From the FDA Drug Label

For patients with CKD on dialysis: Initiate PROCRIT treatment when the hemoglobin level is less than 10 g/dL. If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of PROCRIT.

The protocol for initiating dialysis in a patient with Chronic Kidney Disease (CKD) and Impaired Renal Function is not directly addressed in the provided drug label. However, the label does provide guidance on when to initiate PROCRIT treatment for patients with CKD on dialysis, which is when the hemoglobin level is less than 10 g/dL 2.

• Key points:
  • Initiate PROCRIT treatment when hemoglobin level is less than 10 g/dL
  • Reduce or interrupt PROCRIT dose when hemoglobin level approaches or exceeds 11 g/dL Note that the label does not provide a protocol for initiating dialysis itself, but rather for initiating PROCRIT treatment in patients with CKD who are already on dialysis.

From the Research

Protocol for Initiating Dialysis

The protocol for initiating dialysis in patients with Chronic Kidney Disease (CKD) and impaired renal function is based on several factors, including the level of kidney failure and clinical evidence of uremia.

• Current recommendations suggest initiating dialysis when the glomerular filtration rate (GFR) is higher than or equal to 10 mL/min/1.73 m2 3.
• However, recent studies have reported no benefit in patient survival from initiating dialysis treatment at a higher GFR 4, 5.
• In fact, early initiation of dialysis may be associated with a higher mortality rate and no significant benefit in terms of quality of life 3, 6.

Factors to Consider

When deciding on the optimal time to initiate dialysis, several factors should be considered, including:

• The patient's overall health and comorbidities
• The presence of symptoms or signs attributable to kidney failure
• The patient's estimated glomerular filtration rate (eGFR)
• The potential benefits and risks of early versus late initiation of dialysis

Optimal GFR for Initiating Dialysis

The optimal GFR for initiating dialysis is still a topic of debate.

• Some studies suggest that dialysis can be started at a lower GFR (<7.0 mL/min) with careful clinical management 3.
• Others suggest that dialysis can be started even later, at an eGFR <5.7 and mGFR <4.3 mL/min/1.73 m2, in selected patients with careful management of nutritional status, fluid and electrolyte balance, and other factors 4.
• A nationwide cohort study found that initiating dialysis at an eGFR between 6 and 7 mL/min/1.73 m2 was associated with a lower risk of mortality and major adverse cardiovascular events compared to earlier or later initiation 5.

Cost-Effectiveness of Early Dialysis Initiation

The cost-effectiveness of early dialysis initiation is also an important consideration.

• A randomized controlled trial found that planned early initiation of dialysis therapy was associated with higher direct dialysis costs and no improvement in quality of life 6.
• Another study found that conservative management of stage 5-CKD patients under nephrology care was associated with no advantage of dialysis over conservative management in terms of survival, hospitalization, or quality of life 7.