Indications for Initiation of Hemodialysis in ESRD
Patients with End-Stage Renal Disease (ESRD) should be advised to initiate hemodialysis when weekly renal Kt/Vurea falls below 2.0, unless specific conditions indicating dialysis is not yet necessary are met. 1
Primary Indications for Hemodialysis Initiation
Laboratory-Based Criteria
- Weekly renal Kt/Vurea below 2.0, which approximates a renal urea clearance of 7 mL/min and a renal creatinine clearance between 9-14 mL/min/1.73 m² 1
- GFR approximately 10.5 mL/min/1.73 m² (estimated by the arithmetic mean of urea and creatinine clearances) 1
- Patients with diabetes may require initiation at higher levels of residual kidney function than non-diabetic patients 1
Clinical Indications
- Development of uremic symptoms despite optimal medical management 1
- Protein-energy malnutrition (PEM) that develops or persists despite vigorous attempts to optimize protein and energy intake 1
- Volume overload refractory to diuretics 2
- Uncontrollable hyperkalemia or metabolic acidosis 3
- Uremic pericarditis, encephalopathy, or neuropathy 4
Exceptions When Dialysis May Be Delayed Despite Kt/Vurea < 2.0
Dialysis may be delayed if ALL of the following conditions are met:
Stable or increased edema-free body weight with:
- Lean body mass ≥63%
- Subjective global assessment score indicating adequate nutrition
- Serum albumin concentration above the lower limit of normal and stable or rising 1
Complete absence of clinical signs or symptoms attributable to uremia 1
Approach to Dialysis Initiation
Assessment Algorithm
- Calculate weekly renal Kt/Vurea (normalized to total body water) 1
- Assess for uremic symptoms:
- Evaluate nutritional status:
- Check for refractory complications:
Timing Considerations
- Early dialysis initiation (eGFR >10 mL/min/1.73 m²) has not shown morbidity or mortality benefits 5
- In asymptomatic patients with stage 5 CKD, dialysis may be safely delayed until eGFR is as low as 5-7 mL/min/1.73 m² with careful clinical follow-up 5
- Planned elective dialysis initiation shows reduced risk of overall mortality and hospitalization compared to urgent or unplanned starts 6
- Patients initiating dialysis due to volume overload may have increased mortality risk compared to those initiating due to laboratory evidence of kidney function decline 2
Special Considerations
Older Patients and Comorbidities
- Decision to initiate dialysis in elderly patients should carefully weigh risks against benefits due to comorbidities and frailty 5
- Conservative care without dialysis may be appropriate for some patients with limited life expectancy or severe comorbidities 4
Vascular Access Planning
- For patients choosing hemodialysis, timely creation of arteriovenous fistula (AVF) or arteriovenous graft (AVG) is recommended over tunneled central venous catheters 7
- Preservation of peripheral veins is important for patients with stage III to V chronic kidney disease 4
Common Pitfalls and Caveats
- Relying solely on estimated GFR for dialysis initiation decisions (eGFR formulas are inaccurate in ESRD) 5
- Delaying dialysis until severe uremic symptoms develop, which is associated with worse outcomes 1
- Failing to recognize and address malnutrition, which is associated with increased mortality in patients beginning dialysis 1
- Not providing adequate patient education about dialysis initiation, which should be a shared decision between physician, patient, and family members 5
- Initiating dialysis too early (eGFR >10 mL/min/1.73 m²) without clear clinical indications, which provides no survival benefit 5