What is the initial recommendation for dialysis treatment in patients with impaired renal function?

Initial Recommendations for Dialysis Treatment in Patients with Impaired Renal Function

The decision to initiate maintenance dialysis should be based primarily on an assessment of uremic signs/symptoms, evidence of protein-energy wasting, and inability to safely manage metabolic abnormalities or volume overload with medical therapy, rather than on a specific GFR threshold. 1

Timing of Dialysis Initiation

• Patients who reach CKD stage 4 (GFR < 30 mL/min/1.73 m²) should receive education about kidney failure treatment options, including kidney transplantation, peritoneal dialysis, hemodialysis (home or in-center), and conservative management 1
• While theoretical considerations previously supported dialysis initiation at a GFR of approximately 10 mL/min/1.73 m², there is no clear survival advantage to starting dialysis at higher versus lower GFRs when corrections are made for lead-time bias 1
• Patients with comorbidities typically initiate dialysis at higher estimated GFR levels (10-10.5 mL/min/1.73 m²) compared to younger and healthier patients (7-9 mL/min/1.73 m²) 1
• The IDEAL Study from New Zealand and Australia found no mortality benefit to starting dialysis at higher eGFR (10-14 mL/min/1.73 m²) versus lower eGFR (5-7 mL/min/1.73 m²) levels 2

Clinical Indications for Dialysis Initiation

Dialysis should be initiated when one or more of the following conditions are present:

• Persistent signs and symptoms of uremia (nausea, fatigue, cognitive impairment) 1, 2
• Volume overload refractory to diuretics (dyspnea, peripheral edema) 1, 2
• Metabolic acidosis unresponsive to medical management 2
• Hyperkalemia not controlled by dietary and medical interventions 2
• In patients with CKD and estimated GFR < 15 mL/min/1.73 m², if protein-energy malnutrition develops despite attempts to optimize protein-energy intake with no apparent cause other than low nutrient intake 1

First Dialysis Treatment Approach

When initiating the first dialysis treatment, a "low and slow" approach is recommended:

• The initial session should be shorter (2-2.5 hours) with reduced blood flow rates (200-250 mL/min) and lower dialysate flow rates 3
• Ultrafiltration should be minimal during the first session, focusing primarily on clearance rather than fluid removal 3
• Gradually increase the dialysis dose over subsequent sessions as the patient tolerates treatment 3
• Monitor vital signs frequently (every 15-30 minutes) and observe closely for neurological symptoms during the initial treatment 3

Specific Risks of Aggressive Initial Dialysis

• Dialysis disequilibrium syndrome: Rapid urea removal creates an osmotic gradient between brain and blood, leading to cerebral edema with symptoms including headache, nausea, seizures, and potentially coma 3
• Hemodynamic instability: Rapid fluid removal can cause hypotension, particularly in patients with cardiovascular comorbidities 3
• Electrolyte imbalances: Rapid correction of electrolyte abnormalities can lead to cardiac arrhythmias 3

Dialysis Modality Selection

• Both hemodialysis (HD) and peritoneal dialysis (PD) are viable options with no significant difference in 5-year mortality between modalities 2
• For patients eligible for self-therapy with no medical contraindications, allow patient preference to guide modality choice 1
• PD may show a survival advantage in the first 1.5-2 years of dialysis, especially in non-diabetic patients and young patients with diabetes 4
• For peritoneal dialysis initiation, if possible, wait 10 days to 2 weeks after catheter placement to start PD 1
• If PD must be started sooner, use low-volume, supine dialysis 1

Hemodialysis Adequacy Measurement

• For patients on thrice-weekly hemodialysis, target a single pool Kt/V (spKt/V) of 1.4 per session, with a minimum delivered spKt/V of 1.2 1
• For hemodialysis schedules other than thrice weekly, target a standard Kt/V of 2.3 volumes per week with a minimum delivered dose of 2.1 1
• In patients with significant residual native kidney function, the dose of hemodialysis may be reduced provided residual function is measured periodically 1

Common Pitfalls to Avoid

• Initiating dialysis based solely on GFR without considering clinical symptoms can lead to unnecessary early dialysis with no survival benefit 1, 2
• Failing to educate patients about all available modality options (home HD, PD, in-center HD) limits patient choice and may lead to suboptimal modality selection 5
• Starting with overly aggressive dialysis can cause disequilibrium syndrome, hemodynamic instability, and electrolyte imbalances 3
• Neglecting to measure and account for residual kidney function when determining dialysis prescription 1
• Overlooking the importance of vascular or peritoneal access planning, which should begin well before dialysis is needed 1