From the Guidelines
Dialysis is indicated for patients with end-stage kidney disease or acute kidney injury when the kidneys can no longer adequately filter waste products and maintain fluid balance, and the decision to initiate dialysis should be based on symptoms rather than laboratory values alone, with consideration of individual factors such as uremic symptoms, fluid overload, electrolyte abnormalities, and metabolic acidosis 1. The primary indications for dialysis include:
- Severe uremia (elevated blood urea nitrogen and creatinine) causing symptoms like nausea, vomiting, confusion, or seizures
- Refractory fluid overload unresponsive to diuretics
- Severe electrolyte abnormalities (particularly hyperkalemia >6.5 mEq/L) that don't respond to medical management
- Metabolic acidosis with pH <7.2
- Certain drug or toxin overdoses Clinicians should consider dialysis when the glomerular filtration rate (GFR) falls below 15 mL/min/1.73m², though the decision is individualized based on symptoms rather than laboratory values alone, as evidenced by the IDEAL Study, which found no significant difference in clinical outcomes between early and late initiation of dialysis 1. Dialysis may be initiated earlier in patients with diabetes, heart failure, or other comorbidities that exacerbate kidney dysfunction, and the choice between hemodialysis and peritoneal dialysis depends on patient preference, medical stability, vascular access options, and lifestyle considerations 1. The timing of dialysis initiation should be a compromise designed to maximize a patient’s quality of life by extending the dialysis-free period while avoiding complications that will reduce the length and quality of dialysis-assisted life, and efforts should be directed at preparing patients for a seamless and safe transition to kidney replacement therapy 1.
From the Research
Indications for Dialysis
The decision to initiate dialysis is complex and influenced by various factors, including symptoms and signs of end-stage kidney disease (ESKD) 2. The following are some indications for dialysis:
- Persistent signs and symptoms of uremia, such as nausea and fatigue 3
- Volume overload, including dyspnea and peripheral edema 3
- Worsening estimated glomerular filtration rate (eGFR) 3
- Metabolic acidosis and hyperkalemia 3
- ESKD-related symptoms and signs, which are the most common indications for dialysis initiation 2
Estimated Glomerular Filtration Rate (eGFR) and Dialysis Initiation
There is no recommended eGFR threshold for initiating dialysis, and the decision should be based on patient-clinician shared decision-making 3. Studies have shown that early dialysis initiation (eGFR > 10 mL/min/1.73 m2) is not associated with a morbidity and mortality benefit 2, 4. In fact, early initiation may be associated with a survival disadvantage after lead-time correction 4.
Patient-Specific Factors
The decision to initiate dialysis should be tailored to the individual patient's needs, taking into account their symptoms, laboratory trajectories, patient preferences, and therapy cost and availability 3. Older patients with comorbidities and frailty may require careful consideration of the risks and benefits of dialysis initiation 2.
Dialysis Modalities
There are two main dialysis modalities: peritoneal dialysis and hemodialysis. No differences in long-term mortality rates have been shown between the two modalities 5. The choice of modality should be based on patient-specific factors and shared decision-making between the patient, physician, and family members 3.