Preparation for Renal Replacement Therapy in Advanced Kidney Disease

Introduction to Renal Replacement Therapy

The American Journal of Kidney Diseases recommends that patients with newly discovered severe renal insufficiency (creatinine >2.5 mg/dL or GFR <15 mL/min/1.73m²) require urgent nephrology referral 1
At GFR 7 mL/min/1.73m², patients are well below the threshold (GFR <15 mL/min/1.73m²) that defines Stage 5 CKD and kidney failure requiring renal replacement therapy 2, 3

Evaluate for life-threatening complications that may require emergency dialysis, including severe hyperkalemia (potassium >6.5 mEq/L or ECG changes) 4
Assess for pulmonary edema unresponsive to diuretics 5
Identify severe metabolic acidosis (pH <7.2) 4
Check for uremic symptoms: pericarditis, encephalopathy, bleeding, intractable nausea/vomiting 4
Evaluate for volume overload refractory to medical management 4

The recommended threshold for initiating kidney replacement therapy is GFR <10 mL/min/1.73m² in the absence of urgent indications, according to the American Journal of Kidney Diseases 1
Individual factors influencing timing include dialysis access availability, transplantation candidacy, peritoneal dialysis eligibility, age, declining nutritional status, fluid balance, and medication compliance 1

For hemodialysis candidates, arteriovenous fistula creation should ideally occur when GFR is 15-20 mL/min/1.73m² to allow maturation before dialysis is needed, as recommended by the American Journal of Kidney Diseases 1
Kidney transplantation is the optimal treatment and may be performed preemptively (before dialysis) or after dialysis initiation, according to the American Journal of Kidney Diseases 1

All renally cleared medications must be dose-adjusted for GFR 7 mL/min/1.73m², as recommended by the Annals of Oncology 3
Avoid nephrotoxic agents: NSAIDs, aminoglycosides, contrast dye (or use with extreme caution and adequate hydration), according to the American Journal of Kidney Diseases and Praxis Medical Insights 1, 4

Anemia management involves checking hemoglobin, iron studies (ferritin, transferrin saturation), vitamin B12, and folate, as recommended by Kidney International 6
Mineral bone disease management involves monitoring calcium, phosphorus, parathyroid hormone, and vitamin D levels, according to the American Journal of Kidney Diseases 1
Acidosis management involves checking serum bicarbonate and considering supplementation if <22 mEq/L, as recommended by the American Journal of Kidney Diseases 1
Hyperkalemia management involves dietary potassium restriction and avoidance of potassium-sparing medications, according to the American Journal of Kidney Diseases 1
Volume status management involves careful fluid and sodium management to avoid both overload and depletion, as recommended by Praxis Medical Insights 4