What are the criteria for initiating hemodialysis (HD) in patients with Chronic Kidney Disease (CKD)?

Criteria for Hemodialysis Initiation in CKD

Hemodialysis should be initiated based on clinical symptoms and complications of kidney failure—not on GFR or creatinine levels alone—typically when patients develop uremic symptoms, refractory fluid overload, uncontrollable electrolyte abnormalities, or progressive malnutrition despite intervention, which usually occurs in the GFR range of 5-10 mL/min/1.73 m².1

Clinical Indications for Dialysis Initiation

The decision to start hemodialysis must be symptom-driven rather than laboratory-driven. Dialysis should be initiated when one or more of the following are present:1, 2

• Uremic symptoms or signs: Serositis (pericarditis, pleuritis), pruritus, uremic encephalopathy, or cognitive impairment 1, 2
• Refractory electrolyte abnormalities: Persistent hyperkalemia or severe metabolic acidosis unresponsive to medical management 1, 2
• Volume management failure: Inability to control volume status or blood pressure despite diuretic therapy, or pulmonary edema 1, 2
• Progressive malnutrition: Deterioration in nutritional status refractory to dietary intervention 1, 2
• Uremic bleeding: Bleeding due to uremic platelet dysfunction 2
• Peripheral neuropathy: Progressive uremic neuropathy 2

GFR Thresholds: Context and Limitations

While symptoms typically manifest when GFR falls between 5-10 mL/min/1.73 m², GFR alone should never be the sole criterion for dialysis initiation.1 The 2015 KDOQI guidelines explicitly state there is no survival advantage to starting dialysis earlier based on GFR measurements alone.1

Key evidence from the IDEAL trial:1

• No mortality benefit was demonstrated when comparing early dialysis initiation (GFR 10-14 mL/min/1.73 m²) versus late initiation (GFR 5-7 mL/min/1.73 m²)
• Quality of life outcomes were similar between groups
• Earlier initiation exposed patients to dialysis-related complications without measurable benefit

Important caveat: Creatinine-based eGFR calculations are particularly unreliable in patients with advanced CKD, especially those with altered muscle mass (elderly, malnourished, or very muscular patients).1, 2, 3 This further supports symptom-based rather than laboratory-based initiation.3

Historical Context: The Shift Away from Early Initiation

Observational studies consistently showed that patients starting dialysis at higher GFR levels had increased mortality risk, not decreased.1 Multiple registry studies from the US, Canada, Europe, and Asia demonstrated hazard ratios of 1.14-2.44 for death when dialysis was initiated at higher versus lower GFR levels.1 This counterintuitive finding reflects that:

• Sicker patients with more comorbidities tend to develop symptoms earlier and thus start dialysis at higher GFR 1
• Lead-time bias confounds observational data 1
• Dialysis itself carries risks (access complications, hemodynamic instability, loss of residual kidney function) that may outweigh benefits when started prematurely 1

Predictors of Earlier Symptom Development

Certain patients require dialysis at higher GFR levels due to earlier symptom onset. Risk factors for requiring earlier dialysis initiation include:4

• Heart failure (adjusted OR 3.68) 4
• Hypoalbuminemia <4.0 g/dL (adjusted OR 2.22) 4
• Elevated BUN/creatinine ratio >15 (adjusted OR 1.92) 4
• Hyperuricemia (adjusted OR 1.84) 4

Clinical implication: Patients with these characteristics warrant closer monitoring and earlier vascular access planning, as they are more likely to develop uremic symptoms at higher GFR levels and may be inadequately prepared for dialysis.4

Timing of Metabolic Complications

Understanding when specific complications emerge helps guide monitoring intensity:5

• Hyperparathyroidism: Begins at GFR ~50 mL/min/1.73 m² 5
• Anemia: Begins at GFR ~44 mL/min/1.73 m² 5
• Metabolic acidosis: Begins at GFR ~40 mL/min/1.73 m² 5
• Hyperkalemia: Begins at GFR ~39 mL/min/1.73 m² 5
• Hyperphosphatemia: Begins at GFR ~37 mL/min/1.73 m² 5

These complications should be managed medically first; their presence alone does not mandate dialysis unless refractory to treatment.1

Conservative Management Threshold

For asymptomatic patients with careful monitoring, dialysis can be safely delayed until eGFR reaches 5-7 mL/min/1.73 m² or lower.3 The 2006 KDOQI guidelines recommended conservative management until GFR <15 mL/min/1.73 m², with theoretical support for initiation around 10 mL/min/1.73 m² only when symptoms develop.1

Preparation Phase: When to Begin Planning

Dialysis access planning should begin when:1, 2

• eGFR falls to 15-20 mL/min/1.73 m² 1, 2
• Patient education about kidney replacement therapy options should occur at CKD stage 4 (GFR <30 mL/min/1.73 m²) 2
• Multidisciplinary care should be established for progressive CKD 1

Critical pitfall: Patients requiring earlier dialysis initiation (those with heart failure, hypoalbuminemia, high BUN/Cr ratio) are less likely to have permanent vascular access at dialysis start.4 These patients need accelerated access planning.

Special Populations

Elderly and frail patients:3

• Dialysis initiation may worsen quality of life and outcomes in this population 3
• Conservative management without dialysis is a legitimate option and should be discussed 1
• The decision requires careful weighing of risks versus benefits 2, 3

Patients with multiple comorbidities:1

• These patients tend to start dialysis at higher GFR due to earlier symptom development 1
• This does not represent optimal care but rather reflects their disease burden 1

Algorithm for Decision-Making

1. Monitor patients with CKD stage 5 (GFR <15 mL/min/1.73 m²) closely for uremic symptoms1
2. Assess for absolute indications: life-threatening hyperkalemia, severe acidosis, refractory volume overload, uremic pericarditis 1, 6
3. Evaluate for relative indications: progressive malnutrition, cognitive decline, pruritus, neuropathy 1, 2
4. If asymptomatic and GFR 5-10 mL/min/1.73 m²: Continue conservative management with close follow-up 1, 3
5. If symptomatic at any GFR: Initiate dialysis regardless of laboratory values 1
6. Consider patient-specific factors: Comorbidities, frailty, access readiness, transplant candidacy 1

The overarching principle: Maximize dialysis-free time while preventing complications that would decrease length and quality of dialysis-assisted life.1