When should dialysis be initiated in a chronic kidney disease patient whose estimated glomerular filtration rate has fallen to about 15 mL/min/1.73 m² and who has uremic symptoms, refractory hyperkalemia, severe metabolic acidosis, volume overload, uncontrolled hypertension, malnutrition, or other life‑threatening complications?

Indications for Dialysis Initiation in Chronic Kidney Disease

Dialysis should be initiated based on clinical symptoms and complications—not on GFR thresholds alone—even when eGFR falls to 15 mL/min/1.73 m² or lower. 12

Absolute Clinical Indications for Immediate Dialysis

Regardless of GFR level, dialysis must be started when any of the following uremic complications develop:

Uremic Symptoms

• Pericarditis (pericardial friction rub or effusion) 12
• Encephalopathy (confusion, asterixis, seizures) 23
• Intractable nausea or vomiting unresponsive to antiemetic therapy 23
• Bleeding diathesis due to uremic platelet dysfunction 23
• Peripheral neuropathy attributable to uremia 1

Metabolic Derangements

• Severe hyperkalemia (>6.5 mmol/L or any level with ECG changes) refractory to medical management (dietary restriction, diuretics, potassium binders, insulin/dextrose) 23
• Severe metabolic acidosis (pH <7.20 or bicarbonate <10 mmol/L) unresponsive to oral alkali therapy 23

Volume and Blood Pressure

• Refractory volume overload (persistent pulmonary edema, peripheral edema, dyspnea) despite maximal diuretic therapy 123
• Uncontrolled hypertension despite optimal medical management 123

Nutritional Status

• Protein-energy malnutrition that persists despite aggressive nutritional interventions, with no other identifiable cause 124

GFR Thresholds and Timing

• Conservative management should continue until eGFR falls below 15 mL/min/1.73 m² unless the above clinical indications appear 12
• The target GFR for initiation is approximately 10 mL/min/1.73 m² based on theoretical considerations 2
• In practice, the mean GFR at dialysis initiation is 9.8 mL/min/1.73 m² (range 7–9 for younger adults, 10–10.5 for elderly patients) 2
• Asymptomatic patients can safely defer dialysis until measured GFR reaches 5–7 mL/min/1.73 m² with careful clinical monitoring 256

Evidence Against Early Initiation

The IDEAL randomized controlled trial definitively showed that initiating dialysis at higher GFR (10–14 mL/min/1.73 m²) provides no survival benefit compared to symptom-driven initiation (actual start ≈7–8 mL/min/1.73 m²). 25

Key findings from this high-quality evidence:

• No difference in all-cause mortality between early and late start groups 2
• No difference in cardiovascular events or infectious complications 2
• Similar quality-of-life scores in both groups 2
• Patients in the late-start arm gained a median 5.6-month longer dialysis-free interval 2

After correcting for lead-time bias, observational studies consistently demonstrate no survival advantage and possibly worse outcomes with early initiation 27

Critical Limitations of eGFR in Advanced CKD

Serum creatinine-based eGFR is unreliable when GFR <15 mL/min/1.73 m² and should not be the sole basis for dialysis initiation. 168

• In patients with low muscle mass (elderly, malnourished, sarcopenic), eGFR overestimates true GFR 2
• When clinical symptoms appear discordant with eGFR, obtain a measured GFR using 24-hour urine collection for creatinine and urea clearances 12
• The MDRD equation at a cutoff of 19.7 mL/min/1.73 m² corresponds to a true measured GFR of 15 mL/min/1.73 m² 9

Risks of Dialysis Itself

Dialysis is not benign and carries significant risks that must be weighed against benefits:

• Hemodialysis-related hypotension accelerates loss of residual kidney function, which is critical for volume control, phosphate clearance, and quality of life 23
• Vascular access complications (infection, thrombosis) increase morbidity 2
• Catheter-related bloodstream infections occur at 1.1–5.5 episodes per 1000 catheter-days, affecting ~50% of patients within 6 months 5
• Peritonitis occurs at 0.26 episodes per patient-year, affecting ~30% in the first year of peritoneal dialysis 5
• Dialysis does not replace all native kidney functions and imposes substantial physical, psychological, and economic burdens 2

Monitoring Protocol for Safe Deferral

When deferring dialysis in asymptomatic patients with eGFR <15 mL/min/1.73 m²:

• Measured GFR (24-hour urine creatinine and urea clearance) every 3 months 23
• Serum creatinine, eGFR, and potassium at least monthly, increasing to weekly if rapid progression occurs 3
• Blood pressure at every clinic visit (minimum every 3 months) 3
• Nutritional status (edema-free body weight, serum albumin) every 3 months 23
• Hemoglobin every 3 months 4
• Calcium, phosphorus, PTH every 3–6 months 4

Initial Dialysis Prescription

When dialysis is initiated, use a "low and slow" approach to prevent dialysis disequilibrium syndrome:

• Initial session duration: 2–2.5 hours (not full 4 hours) 2
• Reduced blood flow rates: 200–250 mL/min 2
• Minimal ultrafiltration during first session, focusing on clearance rather than fluid removal 2
• Gradual dose escalation over subsequent sessions as tolerated 2

Common Pitfalls to Avoid

• Never initiate dialysis based solely on eGFR threshold without clinical symptoms 236
• Do not rely on serum creatinine alone—always calculate eGFR or measure GFR directly 48
• Avoid aggressive first dialysis sessions that risk disequilibrium syndrome 23
• Do not discontinue ACE inhibitors/ARBs prematurely when creatinine rises <30% from baseline 43
• Recognize selection bias in observational data: sicker patients start earlier and have worse outcomes due to underlying illness, not timing of dialysis 2

Conservative Management Option

All patients with stage 5 CKD must be offered discussion of conservative (non-dialysis) management as a legitimate treatment option, particularly those who are older, frail, or have multiple comorbidities. 4 This approach focuses on maximizing quality of life through dietary therapy, pharmacological management of uremic symptoms, and palliative care principles. 1