How do I explain to a relative that a patient with impaired renal function and severe metabolic acidosis requires dialysis, when the relative believes the patient's kidneys are fine based on information from a medical location?

Explaining the Need for Dialysis Despite Conflicting Information

The decision to initiate dialysis is based on clinical symptoms and metabolic complications—not just kidney function numbers—and when a patient has severe metabolic acidosis with impaired renal function, dialysis is indicated regardless of what other providers may have said about kidney function being "fine." 1

Understanding the Disconnect

The relative likely heard that "the kidneys are fine" based on a single measurement or incomplete assessment, but this fundamentally misunderstands what determines dialysis need. Here's how to explain this:

What Actually Triggers Dialysis

Dialysis initiation should be based primarily on clinical signs and symptoms of uremia, evidence of protein-energy wasting, and the inability to safely manage metabolic abnormalities (like severe acidosis) or volume overload with medical therapy—not on a specific kidney function number alone. 1

The key indications present in this patient include:

• Severe metabolic acidosis refractory to bicarbonate therapy is an absolute indication for dialysis initiation, particularly when pH remains critically low despite medical intervention 2
• Metabolic acidosis is almost invariably a consequence of advanced renal failure and is associated with multiple adverse effects including negative nitrogen balance, increased protein breakdown, anorexia, cardiovascular dysfunction, and progression of kidney disease 3, 4, 5
• Even "minor" degrees of metabolic acidosis are deleterious and require correction 4

The Specific Conversation Framework

Tell the relative: "I understand [LOCATION] may have said the kidneys are functioning at a certain level, but what matters for dialysis decisions isn't just one kidney function number—it's whether the kidneys can keep the body's chemistry safe. Right now, the patient has severe acid buildup in the blood (metabolic acidosis) that we cannot control with medications alone. This acid buildup is directly life-threatening and causes the heart to malfunction, breaks down muscle and protein, and damages multiple organs. When we cannot safely manage this metabolic problem with medicine, dialysis becomes necessary to prevent death—regardless of what the kidney function number shows." 1, 2

The Clinical Reality of "Fine" Kidneys

Why Numbers Can Be Misleading

• A patient can have measurable kidney function (GFR 10-15 mL/min) but still require dialysis if they have uremic symptoms, severe metabolic derangements, or protein-energy wasting 1
• The presence of severe metabolic acidosis that cannot be corrected medically indicates the kidneys have lost their ability to maintain acid-base homeostasis—this is kidney failure by definition, even if some filtration remains 6, 3, 5
• Metabolic acidosis in hemodialysis patients is determined by protein breakdown, dialysis dose requirements, and the kidney's inability to excrete acid—all indicating need for renal replacement therapy 6

Common Pitfall to Avoid

Never allow the conversation to become about "who is right"—the other location or you. Instead, frame it as: "Different providers may focus on different measurements. What I'm focusing on is the dangerous acid level in the blood that is immediately life-threatening and cannot be fixed without dialysis. This is an emergency situation that requires action now." 2

The Urgency Component

Severe metabolic acidosis refractory to medical management requires dialysis initiation within hours to days, not weeks. 2 This is not a situation where you can "wait and see" or try more conservative measures.

Specific Talking Points

• "The body's acid level is so high that it's affecting heart rhythm, breathing, and consciousness" 2
• "We've tried giving bicarbonate (or other medications), but the kidneys cannot clear the acid fast enough to keep up" 6, 4
• "Without dialysis to remove this acid, the patient will develop life-threatening complications including cardiac arrest" 2
• "This is similar to saying someone's heart is 'fine' when they're having a heart attack—the organ may still be beating, but it's not doing its job safely" 1

Addressing Protein-Energy Wasting

If present, this strengthens your case further:

If protein-energy malnutrition develops or persists despite vigorous nutritional optimization in a patient with advanced kidney disease, dialysis initiation is recommended because the uremic state itself prevents adequate nutrition. 1, 7 This means:

• Declining edema-free body weight 2
• Falling serum albumin 2
• Deteriorating nutritional parameters despite feeding attempts 1, 7

The Bottom Line for the Family

"The kidneys may still be filtering some waste, but they have completely lost the ability to keep the blood chemistry safe. The severe acid buildup is immediately life-threatening. Dialysis is not optional—it is life-saving treatment that must begin now. Waiting will result in cardiac arrest, coma, or death." 2, 1

Documentation Strategy

Document in your note:

• Specific metabolic acidosis values (pH, bicarbonate level) 6, 3
• Failed medical management attempts (bicarbonate administration, doses given) 2, 6
• Clinical symptoms present (altered mental status, respiratory compensation, cardiac effects) 2
• Explanation provided to family about absolute indication for dialysis 1, 8

This creates a clear medical record showing dialysis was indicated by established guidelines, not by subjective interpretation. 1, 2