When is dialysis indicated for patients with impaired renal function, such as end-stage renal disease (ESRD) or acute kidney injury (AKI)?

Dialysis Indications in Renal Failure

Dialysis should be initiated immediately when patients develop life-threatening complications (severe hyperkalemia with arrhythmias, refractory metabolic acidosis, uremic pericarditis, or refractory pulmonary edema), regardless of GFR, and should NOT be based on GFR thresholds alone. 1

Absolute Indications Requiring Immediate Dialysis

These conditions mandate urgent dialysis initiation:

• Severe hyperkalemia causing cardiac arrhythmias or ECG changes that fail to respond to medical management (calcium, insulin/glucose, beta-agonists, sodium bicarbonate) 1, 2
• Refractory metabolic acidosis unresponsive to bicarbonate therapy 1, 2
• Uremic complications including pericarditis, encephalopathy, or bleeding diathesis 1, 2
• Refractory volume overload causing pulmonary edema or cardiac compromise despite maximal diuretic therapy 1, 2

Critical pitfall: Delaying dialysis while attempting further hemodynamic optimization in patients with these absolute indications increases mortality 1, 2

Clinical Symptoms Warranting Dialysis

Symptomatic uremia indicates dialysis need even without life-threatening complications:

• Uremic symptoms: intractable nausea/vomiting, severe pruritus, altered mental status, asterixis 1
• Serositis: pericarditis or pleuritis attributable to uremia 1
• Progressive nutritional deterioration refractory to dietary intervention, manifested by declining serum albumin, decreasing edema-free body weight, or deteriorating nutritional assessment 1

GFR-Based Considerations (Not Sole Criteria)

GFR provides context but should never be the only factor:

• GFR < 15 mL/min/1.73 m² defines kidney failure, with approximately 98% of U.S. patients beginning dialysis at this threshold 1
• GFR 5-10 mL/min/1.73 m² is when uremic symptoms typically develop, but timing varies significantly between individuals 1
• Weekly Kt/V < 2.0 suggests consideration for dialysis unless specific exceptions apply 1

Exceptions to dialysis despite low GFR: Patients with stable or increasing edema-free body weight, adequate nutritional markers, and complete absence of uremic symptoms may defer dialysis 1

Predictors of Earlier Dialysis Need

Certain patients require dialysis at higher GFR levels than others:

• Heart failure (adjusted OR 3.68) 3
• Serum albumin < 4.0 g/dL (adjusted OR 2.22) 3
• BUN/Creatinine ratio > 15 mg/mg (adjusted OR 1.92) 3
• Hyperuricemia (adjusted OR 1.84) 3

These patients warrant earlier vascular access creation and predialysis counseling 3

Modality Selection Based on Clinical Context

For Chronic Kidney Disease/ESRD:

• Conventional intermittent hemodialysis (3 times/week, 3-4 hours per session) is the standard first-line treatment for stable ESRD patients 1, 4
• Preemptive transplantation should be considered when GFR < 20 mL/min/1.73 m² with evidence of progressive, irreversible CKD over 6-12 months 1

For Acute Kidney Injury:

• Hemodynamically stable patients: Intermittent hemodialysis is acceptable 1, 4, 2
• Hemodynamically unstable patients: Continuous renal replacement therapy (CRRT) or prolonged intermittent renal replacement therapy (PIRRT) are preferred due to superior hemodynamic stability and slower solute shifts 1, 4, 2

Critical pitfall for patients with severe coronary artery disease: Avoid standard intermittent hemodialysis in hemodynamically unstable patients, as rapid fluid shifts can precipitate cardiac ischemia or arrhythmias 2

For Hypercatabolic States:

• Patients with hyperkalemia-induced arrhythmias may require multiple dialysis treatments per day for adequate potassium control 2
• CRRT offers more stable hyperkalemia control compared to intermittent hemodialysis 2

Conservative Management Alternative

For patients who decline renal replacement therapy:

• Comprehensive conservative management should be offered, including advance care planning, symptom and pain management protocols, and psychological, spiritual, and culturally sensitive care 1

Key Clinical Algorithm

1. Assess for absolute indications (hyperkalemia with arrhythmias, refractory acidosis, uremic complications, refractory volume overload) → If present, initiate dialysis immediately
2. Evaluate for uremic symptoms (nausea/vomiting, encephalopathy, pericarditis, nutritional decline) → If present, initiate dialysis
3. Check GFR and clinical trajectory → If GFR < 15 mL/min/1.73 m² with declining nutritional status or symptoms, initiate dialysis
4. Select modality based on hemodynamic stability → Stable patients receive intermittent hemodialysis; unstable patients receive CRRT/PIRRT
5. Consider patient preferences → Offer conservative management if dialysis declined