When is dialysis (Dialysis) indicated in patients with impaired renal function (Renal Impairment)?

Indications for Dialysis in Patients with Impaired Renal Function

Dialysis should be initiated based on clinical symptoms and signs of kidney failure—not on GFR alone—including serositis, refractory acid-base or electrolyte abnormalities, pruritus, inability to control volume status or blood pressure, progressive malnutrition despite dietary intervention, or cognitive impairment, which typically occurs at GFR 5-10 mL/min/1.73 m² but may occur outside this range. 1, 2

Symptom-Based Indications (Primary Criteria)

The decision to start dialysis must be driven by uremic symptoms rather than laboratory values alone. 1, 3 The following clinical manifestations mandate dialysis consideration:

Absolute Indications

• Serositis: Uremic pericarditis or pleuritis requiring immediate dialytic intervention 1, 2, 4
• Severe electrolyte abnormalities: Life-threatening hyperkalemia (>6.0 mmol/L) unresponsive to medical therapy, or moderate hyperkalemia (5.3-6.0 mmol/L) with ECG changes 2, 4
• Refractory metabolic acidosis: Severe acidosis not controlled by conservative measures 2, 4
• Volume overload: Inability to control fluid status or blood pressure despite diuretics 1, 2
• Uremic encephalopathy: Cognitive impairment or altered mental status attributable to uremia 1, 2, 4
• Uremic neuropathy: Peripheral neuropathy from advanced uremic toxicity 4
• Pruritus: Severe, refractory itching from uremia 1, 2

Progressive Clinical Deterioration

• Nutritional decline: Progressive malnutrition with declining serum albumin and body weight despite dietary intervention 1, 2
• Nausea/vomiting: Persistent uremic gastrointestinal symptoms 2

GFR-Based Considerations (Secondary Criteria)

While GFR should not be the sole determinant, it provides context for timing:

• Adults: Consider dialysis when weekly renal Kt/Vurea falls below 2.0 (approximating GFR ~10.5 mL/min/1.73 m²), but symptoms should guide the final decision 2
• Pediatric patients: Consider at GFR 9-14 mL/min/1.73 m² and recommend at GFR ≤8 mL/min/1.73 m² 2
• Asymptomatic patients: Dialysis may be safely delayed until eGFR is 5-7 mL/min/1.73 m² with careful clinical follow-up and adequate patient education 3

Critical caveat: Creatinine-based eGFR formulae are inaccurate in ESRD, so do not rely solely on eGFR values. 3 Early dialysis initiation (eGFR >10 mL/min/1.73 m²) provides no morbidity or mortality benefit per the IDEAL study. 3

Emergent Dialysis Indications

Certain life-threatening conditions require urgent dialysis regardless of GFR:

• Severe hyperkalemia: Persistent elevation >6.0 mmol/L or any level with ECG changes unresponsive to medical therapy 4
• Severe hyperphosphatemia: Progressive elevation >6 mg/dL warranting prophylactic dialysis before overt uremic symptoms 4
• Uremic pericarditis: Absolute indication for immediate hemodialysis 4
• Tumor lysis syndrome: Requires frequent (daily) dialysis for continuous metabolite removal 4

Pre-Dialysis Monitoring and Referral

To optimize timing and preparation:

• Nephrology referral: Refer when GFR <30 mL/min/1.73 m² or when 1-year risk of kidney failure is 10-20% or higher 2
• Clinical monitoring: Assess patients approaching dialysis need monthly for clinical status 2
• Residual kidney function: Measure every 3 months in patients approaching dialysis 2
• GFR estimation: Average measured creatinine and urea clearances using timed urine collection for more accurate assessment 2

Dialysis Modality Selection

For emergent situations requiring rapid solute removal, intermittent hemodialysis (IHD) should be the initial modality, as it provides superior efficiency for removing urea, potassium, phosphate, and uric acid. 4

• IHD: Preferred for most patients requiring rapid electrolyte and solute removal 4
• Continuous renal replacement therapy (CRRT): Reserved for hemodynamically unstable patients, provides better azotemia control and allows improved nutritional support 4
• Peritoneal dialysis: Consider for chronic management in resource-limited settings or based on patient preference 5
• Selection factors: Patient/family choice, patient size, medical comorbidities, and family support 2

Special Populations

Elderly and Frail Patients

Due to comorbidities and frailty, dialysis initiation may worsen outcomes and quality of life in older patients. 3 The decision must carefully weigh risks versus benefits, with conservative care being appropriate in many cases. 3

Pregnant Women

Pregnant women with ESRD should receive long frequent hemodialysis either in-center or at home. 2

Patients with Sepsis

CKD stage 4-5 patients with sepsis may require urgent dialysis if refractory fluid overload develops despite careful fluid management. 2

Conservative Management Option

Conservative management should be offered as a legitimate option for patients who choose not to pursue renal replacement therapy, supported by comprehensive symptom management, psychological care, spiritual care, and advance care planning. 1, 2

This approach is particularly appropriate for patients with:

• Limited life expectancy 6
• Severe comorbid conditions 6
• Preference to avoid medical interventions 6

Critical Pitfalls to Avoid

• Do not initiate dialysis based solely on eGFR: Symptom assessment must drive the decision, as eGFR is inaccurate in ESRD 1, 3
• Do not start dialysis too early: Early initiation (eGFR >10 mL/min/1.73 m²) provides no benefit and may cause harm 3
• Do not delay nephrology referral: Late referral leads to poor outcomes and inadequate preparation 2
• Do not treat asymptomatic hypocalcemia: Only symptomatic hypocalcemia (tetany, seizures) requires cautious calcium gluconate; routine supplementation worsens calcium-phosphate precipitation 4
• Preserve peripheral veins: For patients with stage III-V CKD at risk of requiring hemodialysis, avoid unnecessary peripheral IV access 6

Multidisciplinary Approach

Patients with progressive CKD should be managed in a multidisciplinary setting with access to: 1

• Dietary counseling 1
• Education about different RRT modalities 1, 2
• Transplant options (living donor preemptive transplantation should be considered when GFR <20 mL/min/1.73 m² with evidence of progressive irreversible CKD over 6-12 months) 1
• Vascular access surgery planning 1
• Psychological and social care 1