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

Indications for Maintenance Hemodialysis in CKD

Primary Recommendation

Hemodialysis should be initiated based on clinical symptoms and complications of uremia—not on GFR alone—typically when patients develop uremic symptoms, refractory fluid overload, uncontrollable metabolic abnormalities, or progressive malnutrition despite intervention. 1, 2

Absolute Clinical Indications for Dialysis Initiation

Dialysis must be started when any of the following are present, regardless of GFR level:

Uremic Symptoms or Signs

• Pericarditis (uremic pericarditis is an absolute indication) 2, 3
• Encephalopathy or progressive cognitive impairment 1, 2
• Intractable nausea/vomiting unresponsive to antiemetics 2, 3
• Bleeding diathesis from uremic platelet dysfunction 2, 3
• Pruritus refractory to medical management 2
• Peripheral neuropathy attributable to uremia 2

Volume Management Failure

• Pulmonary edema or inability to control volume status despite maximal diuretic therapy 1, 2, 3
• Uncontrolled hypertension despite maximal medical management 2, 3

Metabolic Derangements

• Severe hyperkalemia (typically >6.5 mEq/L) unresponsive to medical therapy 2, 3
• Severe metabolic acidosis (typically pH <7.2 or bicarbonate <12 mEq/L) refractory to oral alkali therapy 2, 3

Nutritional Deterioration

• Protein-energy malnutrition that develops or persists despite vigorous attempts to optimize protein and energy intake, with no apparent cause other than uremia 1, 2, 3
• Progressive decline in edema-free body weight 3
• Falling serum albumin (<4.0 g/dL is associated with earlier need for dialysis) 4

GFR Thresholds: Context and Critical Limitations

GFR alone should NEVER be the sole criterion for dialysis initiation. 1, 2, 3 The 2015 KDOQI guidelines explicitly state there is no survival advantage to starting dialysis earlier based on GFR measurements alone. 1, 2

When to Monitor Closely

• Conservative management should continue until GFR <15 mL/min/1.73 m² unless specific clinical indications exist 2, 3
• Target GFR for initiation is approximately 5-10 mL/min/1.73 m² when symptoms develop 1, 2, 5
• The landmark IDEAL trial demonstrated 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) 5, 6

Critical Caveat About GFR Estimation

• Creatinine-based eGFR formulas are inaccurate in advanced CKD 3, 6
• For patients with unusual creatinine generation or altered tubular secretion, obtain measured GFR using 24-hour urine collection for creatinine and urea clearance 7, 3

When Dialysis Can Be Safely Deferred (Even with GFR <10)

Dialysis may be safely delayed even when GFR <10 mL/min/1.73 m² if ALL of the following are present: 3

• Stable or increased edema-free body weight
• Adequate nutritional parameters (albumin ≥4.0 g/dL)
• Complete absence of clinical signs or symptoms attributable to uremia
• Ability to control volume status and blood pressure with medical therapy
• No severe metabolic derangements

Predictors of Earlier Dialysis Need

Certain patients require dialysis at higher GFR levels. Monitor more closely and prepare earlier if the patient has: 4

• Heart failure (3.68-fold increased odds of early initiation)
• Serum albumin <4.0 g/dL (2.22-fold increased odds)
• BUN/creatinine ratio >15 (1.92-fold increased odds)
• Hyperuricemia (1.84-fold increased odds)

Preparation Phase: Critical Timing

While waiting for clinical indications to develop:

Patient Education

• Begin education about kidney replacement therapy options at CKD stage 4 (GFR <30 mL/min/1.73 m²) 1, 2
• Discuss hemodialysis (in-center or home), peritoneal dialysis, kidney transplantation, and conservative management 1

Vascular Access Planning

• Create vascular access when eGFR falls to 15-20 mL/min/1.73 m² 2, 3
• This allows maturation time for arteriovenous fistula (preferred access) 2
• Patients with predictors of early initiation need earlier access creation to avoid starting with a catheter 4

Initial Dialysis Prescription: "Low and Slow" Approach

When dialysis is initiated, the first treatment MUST use a cautious approach to minimize dialysis disequilibrium syndrome and hemodynamic instability: 7, 3

• Initial session duration: 2-2.5 hours (not full 4 hours) 7, 3
• Reduced blood flow rates: 200-250 mL/min 7, 3
• Minimal ultrafiltration during first session, focusing on clearance rather than fluid removal 7, 3
• Frequent vital sign monitoring every 15-30 minutes with close observation for neurological symptoms 7
• Gradual dose escalation over subsequent sessions as tolerated 7, 3

Critical Pitfalls to Avoid

Do Not Initiate Dialysis Based on GFR Alone

• Early dialysis initiation in asymptomatic patients provides no survival benefit and may cause harm 2, 3, 5
• Observational studies consistently show patients starting dialysis at higher GFR levels had increased mortality risk (hazard ratios 1.14-2.44), not decreased 3
• This reflects patient selection bias—frailer patients with more comorbidities start earlier but don't live as long 3

Recognize the Risks of Dialysis Itself

• Dialysis does not replace all kidney functions and imposes significant burden 7, 3
• Hemodialysis-related hypotension may accelerate loss of residual kidney function 7, 3
• Catheter-related bloodstream infections occur at 1.1-5.5 episodes per 1000 catheter-days, affecting ~50% of patients within 6 months 5
• Vascular access complications are common 7, 3

Avoid Aggressive First Dialysis Sessions

• Rapid removal of uremic toxins can cause cerebral edema, seizures, and cardiovascular instability (dialysis disequilibrium syndrome) 7

Special Populations

Elderly and Frail Patients

• Conservative management without dialysis is a legitimate option for elderly patients with multiple comorbidities 2, 6
• Dialysis initiation may be associated with worse outcomes and quality of life in frail patients 6
• The decision should carefully weigh benefits against risks 6

Patients with Diabetes

• No specific GFR threshold differs for diabetic patients 1
• However, diabetic patients often develop symptoms earlier and may have predictors of early initiation (heart failure, low albumin) 4

Algorithm for Clinical Decision-Making

1. Monitor patients with CKD stage 5 (GFR <15 mL/min/1.73 m²) closely for development of uremic symptoms 2, 3

2. Assess for absolute indications at each visit:

   • Life-threatening hyperkalemia or severe acidosis
   • Uremic pericarditis or encephalopathy
   • Refractory volume overload or pulmonary edema
   • Progressive malnutrition despite intervention 2, 3

3. If absolute indications present: Initiate dialysis regardless of GFR 2, 3

4. If no absolute indications but GFR 5-10 mL/min/1.73 m²: Continue conservative management with close monitoring if patient remains asymptomatic with stable nutrition 3, 6

5. Ensure adequate preparation: Vascular access created, patient educated, multidisciplinary care established 1, 2

6. When initiating: Use "low and slow" first session protocol 7, 3