Dialysis Initiation in Chronic Kidney Disease

CKD Staging and Progression to Dialysis

• The National Kidney Foundation classifies CKD into five stages based on glomerular filtration rate (GFR), with decreasing values indicating progressive loss of kidney function 3

When to Start Dialysis

• The American Journal of Kidney Diseases recommends that dialysis should be considered when patients reach CKD stage 5 (GFR <15 mL/min/1.73 m²) 1, 2
• The decision to initiate dialysis should be based on a combination of GFR estimation and clinical assessment, not solely on GFR values 1

Clinical Indications for Dialysis Initiation

• Uremic complications that may prompt dialysis initiation include malnutrition despite dietary intervention 2, fluid overload unresponsive to diuretics 2, bleeding due to uremic platelet dysfunction 3, uremic serositis (pericarditis, pleuritis) 2, depression and cognitive impairment 2, peripheral neuropathy 2, and electrolyte abnormalities (hyperkalemia, metabolic acidosis) 4

Preparation for Dialysis

• Patients who reach CKD stage 4 (GFR <30 mL/min/1.73 m²) should receive timely education about kidney failure treatment options 1, 2
• Education should cover kidney transplantation, peritoneal dialysis, hemodialysis (home or in-center), and conservative management 1, 2

Special Considerations

• Decision-making is more complex for older and more fragile patients, requiring careful weighing of risks and benefits 1
• Conservative therapy without dialysis may be appropriate for some patients, particularly those with multiple comorbidities or frailty 1, 2

Accurate Assessment of Kidney Function

• GFR should be estimated using validated equations or by measurement of creatinine and urea clearances, not simply by serum creatinine and urea nitrogen levels 1
• In patients with unusual creatinine generation (very muscular or malnourished), GFR should be estimated using methods independent of creatinine generation 4