What are the absolute indications for initiating hemodialysis in a patient with end-stage renal disease (ESRD)?

Absolute Indications for Hemodialysis

The absolute indications for initiating hemodialysis include persistent hyperkalemia, severe metabolic acidosis, volume overload unresponsive to diuretic therapy, and overt uremic symptoms (pericarditis and severe encephalopathy). 1

Life-Threatening Indications Requiring Immediate Dialysis

The following conditions represent absolute indications where dialysis must be initiated urgently to prevent mortality:

Electrolyte Emergencies

• Persistent hyperkalemia that fails to respond to medical management (calcium gluconate, insulin/glucose, salbutamol, resins, diuretics) requires hemodialysis, particularly when GFR is below 10 mL/min 1, 2
• Hyperkalemia with symptoms or electrocardiographic abnormalities necessitates immediate intervention, and if medical therapy fails, dialysis becomes mandatory 2

Acid-Base Crisis

• Severe metabolic acidosis unresponsive to bicarbonate therapy represents an absolute indication for dialysis 1
• This is particularly critical when acidosis contributes to hemodynamic instability or respiratory compromise 1

Volume Overload

• Volume overload unresponsive to diuretic therapy is an absolute indication, especially when manifesting as pulmonary edema 1
• Loop diuretics should be attempted at higher-than-normal doses, potentially combined with thiazides, but dialysis is indicated when medical management fails 2

Uremic Complications

• Overt uremic symptoms constitute absolute indications and include: 1
  • Uremic pericarditis (life-threatening due to risk of tamponade)
  • Severe uremic encephalopathy (altered mental status, seizures)
  • Uremic bleeding that cannot be controlled medically

Relative Indications That May Warrant Prophylactic Dialysis

While not absolutely required, dialysis may be initiated prophylactically in the following scenarios:

• Severe, progressive hyperphosphatemia (>6 mg/dL) before development of overt uremic symptoms 1
• Severe symptomatic hypocalcemia related to hyperphosphatemia 1

Important Clinical Caveats

Timing Considerations

• The appropriate timing for prophylactic dialysis based on hyperphosphatemia or hypocalcemia remains unresolved by current guidelines 1
• The decision to initiate dialysis should be based primarily on signs/symptoms of uremia, protein-energy wasting, and inability to safely manage metabolic abnormalities rather than a specific GFR threshold alone 1

Modality Selection

• For hemodynamically stable patients with ESRD requiring urgent dialysis, conventional intermittent hemodialysis is acceptable 3
• For hemodynamically unstable patients, continuous renal replacement therapy (CRRT) or prolonged intermittent renal replacement therapy (PIRRT) are preferred due to better hemodynamic tolerance 1, 3
• In tumor lysis syndrome specifically, daily dialysis is recommended given continuous release of metabolites from lysed cells 1

Common Pitfalls to Avoid

• Do not wait for a specific GFR threshold (such as <10 mL/min) if absolute indications are present 1
• Hypocalcemia should always be corrected before treating metabolic acidosis in CKD to avoid worsening tetany 2
• Peritoneal dialysis should be reserved for situations where hemodialysis or CRRT are unavailable, as it has lower efficiency for removing solutes and electrolytes in urgent situations 1