From the Guidelines
Dialysis is indicated for patients with end-stage kidney disease (ESKD) or acute kidney injury (AKI) when the kidneys can no longer adequately filter waste products and maintain fluid balance, typically when the glomerular filtration rate (GFR) falls below 15 mL/min/1.73m² with symptoms. The primary indications for initiating dialysis include severe uremia (characterized by symptoms like nausea, vomiting, confusion, and seizures), refractory fluid overload causing respiratory distress, persistent hyperkalemia (potassium >6.5 mEq/L) despite medical management, severe metabolic acidosis (pH <7.2), and certain toxin ingestions 1.
Key Considerations
- The decision to initiate dialysis therapy should be based on individual patient factors, including dialysis accessibility, transplantation option, PD eligibility, home dialysis eligibility, vascular access, age, declining health, fluid balance, and compliance with diet and medications 1.
- For chronic kidney disease patients, dialysis is typically started when the GFR falls below 15 mL/min/1.73m² with symptoms, or sometimes at higher GFR levels if uremic symptoms are present 1.
- Specific laboratory values that often trigger dialysis consideration include BUN >100 mg/dL, creatinine >10 mg/dL, or rapid rises in these values 1.
- Dialysis modalities include hemodialysis, which uses an external filter to clean the blood, and peritoneal dialysis, which uses the patient's peritoneal membrane as a filter 1.
- The choice between modalities depends on patient factors including hemodynamic stability, vascular access, and lifestyle preferences 1.
Additional Recommendations
- Early nephrology consultation is recommended when GFR falls below 30 mL/min/1.73m² to allow for proper planning and education regarding renal replacement therapy options 1.
- For some patients, conservative therapy without dialysis or transplantation is the appropriate option, and the health care team should strive to maximize the quality of life (QOL) and length of life by using dietary and pharmacological therapy to minimize uremic symptoms and maintain volume homeostasis 1.
From the Research
Indications for Dialysis
The decision to initiate dialysis is complex and depends on various factors, including the patient's symptoms, laboratory results, and overall health status. Some of the key indications for dialysis include:
- Persistent signs and symptoms of uremia, such as nausea and fatigue 2
- Volume overload, characterized by dyspnea and peripheral edema 2
- Worsening estimated glomerular filtration rate (eGFR) 2, 3
- Metabolic acidosis and hyperkalemia 2
- Electrolyte disturbances and uremia 4
Timing of Dialysis Initiation
The timing of dialysis initiation is crucial and should be based on individual patient needs. Studies have shown that early dialysis initiation, defined as starting dialysis at an eGFR > 10 mL/min/1.73 m2, is not associated with improved morbidity and mortality outcomes 3, 5. In fact, some studies suggest that early dialysis initiation may be associated with increased mortality risk 5. Therefore, the decision to start dialysis should be based on a comprehensive assessment of the patient's symptoms, laboratory results, and overall health status, rather than solely on eGFR.
Patient-Specific Factors
Patient-specific factors, such as age, comorbidities, and frailty, should also be taken into account when deciding when to initiate dialysis. Older patients, for example, may be at higher risk of complications and may require more careful consideration of the risks and benefits of dialysis 3. Additionally, patients with certain conditions, such as hepatorenal syndrome, cardiorenal syndrome, rhabdomyolysis, and tumor lysis syndrome, may require earlier initiation of dialysis 4.
Shared Decision-Making
The decision to initiate dialysis should be a shared decision between the patient, their family members, and healthcare providers. Patients should be fully informed about the risks and benefits of dialysis, as well as alternative treatment options, such as conservative care 2, 3. This approach ensures that patients receive personalized care that meets their unique needs and preferences.