In patients with end‑stage renal disease (ESRD), what are the indications for initiating dialysis, the preferred dialysis modalities (hemodialysis (HD) versus peritoneal dialysis (PD)), treatment protocols, and management of common complications?

Dialysis Management in End-Stage Renal Disease

Indications for Initiating Dialysis

Initiate dialysis when GFR falls below 10 mL/min/1.73 m² in the presence of uremic symptoms or complications, rather than at a predetermined GFR threshold alone. 1

GFR-Based Thresholds

• Target GFR for initiation is approximately 10-10.5 mL/min/1.73 m², calculated as the arithmetic mean of urea and creatinine clearances 1, 2
• Conservative management is appropriate until GFR decreases below 15 mL/min/1.73 m² unless specific complications develop 1
• Do not initiate dialysis based solely on estimated GFR, as creatinine-based formulae are inaccurate in ESRD and early initiation (eGFR >10 mL/min/1.73 m²) provides no mortality benefit 3, 4
• Asymptomatic patients may safely delay dialysis until eGFR reaches 5-7 mL/min/1.73 m² with careful monitoring 3

Clinical Indications (Regardless of GFR)

Initiate dialysis when any of the following develop:

• Uremic symptoms: nausea, vomiting (present in ~60% at initiation), fatigue, cognitive impairment, peripheral neuropathy, serositis, or bleeding diathesis 1, 5, 4
• Volume overload: persistent dyspnea, peripheral edema unresponsive to diuretics 1, 4
• Metabolic derangements: refractory hyperkalemia, metabolic acidosis 1, 4
• Protein-energy wasting (PEW): involuntary weight loss >6% in <6 months, body weight <90% of standard, serum albumin drop ≥0.3 g/dL to <4.0 g/dL without acute infection, or progressive dietary protein intake decline despite counseling 2, 5

Critical caveat: Delaying dialysis until severe uremic symptoms develop is associated with worse outcomes and increased mortality 5. However, early initiation without symptoms provides no benefit and exposes patients to dialysis-related complications prematurely 1, 3.

Dialysis Modality Selection

Hemodialysis vs. Peritoneal Dialysis

No mortality difference exists between hemodialysis and peritoneal dialysis, so modality selection should be based on patient preference, lifestyle, comorbidities, and access feasibility 6, 4.

Choose Hemodialysis When:

• Patient lacks manual dexterity or cognitive ability for self-care 6
• Inadequate peritoneal membrane function or prior abdominal surgery precludes PD 6
• Patient prefers in-center treatment with less daily responsibility 6

Choose Peritoneal Dialysis When:

• Patient desires home-based therapy with greater autonomy 6
• Preservation of residual kidney function is priority (PD may better preserve RKF) 1
• Patient has difficult vascular access or wishes to avoid needles 6
• Patient requires gentler, continuous solute removal 1

Vascular Access for Hemodialysis

Arteriovenous fistula (AVF) is the preferred access, requiring creation during CKD stage 4 to allow maturation before dialysis initiation 1, 5.

Access hierarchy (in order of preference):

1. AVF: Requires several months to mature; lowest infection risk 5, 6
2. Arteriovenous graft (AVG): Usable in 24 hours to 2 weeks depending on material; intermediate infection risk 6
3. Tunneled central venous catheter: Immediately usable but highest infection risk (1.1-5.5 episodes per 1000 catheter-days, affecting ~50% within 6 months) 6, 4

Preserve peripheral veins in all patients with CKD stage 3-5 by avoiding venipuncture in forearms and antecubital fossae 7.

Hemodialysis Treatment Protocols

Dialysis Adequacy Targets

• Minimum urea reduction ratio (URR) ≥65% or single-pool Kt/V ≥1.2 for thrice-weekly hemodialysis 1
• Higher dialysis doses (Kt/V >1.2) or high-flux membranes provide no additional mortality benefit in patients dialyzed thrice weekly 1
• Weekly renal Kt/Vurea below 2.0 (approximating renal urea clearance of 7 mL/min and creatinine clearance 9-14 mL/min/1.73 m²) indicates need for dialysis initiation 2, 5

Treatment Frequency and Duration

• Standard regimen: 3-4 hours per session, three times weekly 1
• Adjust based on residual kidney function, body size, and volume status 1

Peritoneal Dialysis Treatment Protocols

Adequacy Targets

• Minimum weekly Kt/V targets should guide PD prescription, though specific thresholds vary by residual kidney function 1
• Monitor peritoneal membrane transport characteristics to optimize dialysate dwell times 1

Modality Options

• Continuous ambulatory peritoneal dialysis (CAPD): 4-5 manual exchanges daily 1
• Automated peritoneal dialysis (APD): Cycler-based exchanges overnight 1

Managing Common Dialysis Complications

Infection-Related Complications

Hemodialysis Catheter-Related Bloodstream Infections

• Incidence: 1.1-5.5 episodes per 1000 catheter-days 4
• Affects approximately 50% of patients within 6 months of catheter placement 4
• Prevention: Prioritize AVF/AVG over catheters; use strict aseptic technique for catheter care 6, 4

Peritoneal Dialysis-Related Peritonitis

• Incidence: 0.26 episodes per patient-year, affecting ~30% in first year 4
• Prevention: Meticulous technique during exchanges; prompt recognition of cloudy effluent 4

Intradialytic Hypotension

• Occurs due to rapid fluid removal and loss of residual kidney function 1
• HD-related hypotension may accelerate loss of residual kidney function 1
• Management: Adjust ultrafiltration rate, reassess dry weight, consider cooled dialysate, midodrine for refractory cases 1

Cardiovascular Complications

• Arrhythmias and cardiac arrest are common, driven by electrolyte shifts and volume changes 4
• Blood pressure control improves mortality in dialysis patients 7
• Optimize through adequate dialysis, sodium restriction (rather than excessive antihypertensive medications), and volume management 7

Metabolic and Nutritional Complications

Protein-Energy Wasting

• Monitor: Serum albumin (strong predictor of survival), prealbumin, transferrin, Subjective Global Assessment (SGA), anthropometric measurements, dietary intake 2, 5
• Hemodialysis targets: 1.2 g protein/kg/day (≥50% high biological value), 35 kcal/kg/day for age <60 years, 30-35 kcal/kg/day for age ≥60 years 2
• Peritoneal dialysis targets: 1.2-1.3 g protein/kg/day (≥50% high biological value), same energy targets as HD 2
• Low serum albumin at dialysis initiation independently predicts increased mortality 2

Anemia

• Requires erythropoiesis-stimulating agents and iron supplementation 6, 7
• Monitor hemoglobin and iron parameters regularly 7

Mineral and Bone Disorders

• Hyperphosphatemia: Requires phosphate binders and dietary restriction 6, 7
• Hypocalcemia: May require calcium supplementation and active vitamin D 6, 7
• Monitor parathyroid hormone, calcium, phosphorus regularly 1, 7

Hyperkalemia

• Management: Dietary potassium restriction, adequate dialysis, sodium polystyrene sulfonate for acute episodes 1, 4

Metabolic Acidosis

• Corrected through dialysis; may require bicarbonate supplementation between sessions 6, 4

Access-Related Complications

• AVF/AVG thrombosis: Requires urgent intervention to restore patency 6
• Steal syndrome: Ischemia distal to access; may require access revision 6
• Catheter malfunction: Requires thrombolytic therapy or catheter exchange 6

Pre-Dialysis Preparation (CKD Stage 4)

Begin education and planning when patients reach CKD stage 4 (GFR 15-29 mL/min/1.73 m²) to allow time for informed decision-making and access creation 1.

Patient Education Components

• All kidney replacement therapy options: hemodialysis (in-center and home), peritoneal dialysis (CAPD and APD), kidney transplantation, conservative management 1
• Include family members and caregivers in education 1
• Discuss preemptive kidney transplantation for eligible candidates 1

Pre-Dialysis Nutritional Optimization

Before initiating dialysis, attempt intensive dietary counseling every 1-2 months (more frequently if intake remains inadequate) 2:

• Target protein intake: 0.6-0.75 g/kg/day for CKD patients not yet on dialysis 2
• Target energy intake: 35 kcal/kg/day for age <60 years, 30-35 kcal/kg/day for age ≥60 years 2
• Consider keto-analogs of essential amino acids for protein restriction 1

Monitoring Parameters Before Dialysis

• Nutritional markers: Serum albumin, prealbumin, transferrin, SGA, weight, BMI, dietary intake assessment 2
• Inflammatory markers: CRP to distinguish inflammation from pure malnutrition 2
• GFR estimation: Use validated equations or measured creatinine and urea clearances, not serum creatinine alone 1

Special consideration for diabetic patients: May require dialysis initiation at higher GFR levels and need closer monitoring for accelerated nutritional decline 2, 5. Nutritional deterioration becomes evident when GFR falls below 50 mL/min and is particularly notable below creatinine clearance of 25 mL/min 2.

Special Populations

Elderly and Frail Patients

• Dialysis initiation may be associated with worse outcomes and quality of life due to comorbidities and frailty 3
• Consider conservative management (palliative care without dialysis) as a reasonable alternative for patients with limited life expectancy or severe comorbidities 6, 3, 7
• Decision requires careful weighing of dialysis risks versus benefits through shared decision-making 3, 7

Diabetic Patients

• Insulin is the preferred treatment for diabetes requiring medication in ESRD patients 7
• May require dialysis initiation at higher residual kidney function than non-diabetic patients 2, 5

Conservative Management Without Dialysis

For patients who decline dialysis or for whom dialysis is not appropriate, maximize quality and length of life through 1:

• Low-protein diets (0.6-0.75 g/kg/day) 2
• Keto-analogs of essential amino acids 1
• Loop diuretics for volume management 1
• Sodium polystyrene sulfonate for hyperkalemia 1
• Palliative care and hospice referral for patients with advanced kidney failure 1, 6, 7

Vaccination and Preventive Care

Recommended vaccinations for ESRD patients 7:

• Seasonal influenza (annual)
• Tetanus
• Hepatitis B
• Streptococcus pneumoniae
• Human papillomavirus (through age 26)

Routine cancer screening is discouraged for patients not receiving kidney transplantation 7.

Key Pitfalls to Avoid

• Do not initiate dialysis based solely on GFR threshold without considering symptoms and complications 1, 3
• Do not delay nephrology referral; refer patients with CKD stage 4 to allow adequate pre-dialysis planning 1, 3, 7
• Do not use peripheral arm veins for venipuncture in CKD stage 3-5 patients to preserve future access sites 7
• Do not fail to recognize and address malnutrition, as it is associated with increased mortality at dialysis initiation 2, 5
• Do not assume early dialysis initiation improves outcomes; it does not reduce mortality and exposes patients to complications prematurely 3, 4