Indications for initiation of maintenance dialysis in chronic kidney disease

This algorithm represents a general approach to dialysis initiation in CKD. The specific approach to deciding whether and when to start chronic dialysis should be individualized for each patient and involves extensive collaboration between the patient and the nephrologist. After shared decision-making, many patients with advanced CKD choose conservative kidney management rather than dialysis. Planning for dialysis should be integrated into the overall care of patients with advanced CKD. Ideally, the decision to initiate dialysis is made long after the patient has undergone an evaluation for kidney transplantation, identified their preferred dialysis modality, and has a functioning dialysis access in place.

CKD: chronic kidney disease; AKI: acute kidney injury; GFR: glomerular filtration rate; eGFR: estimated GFR; CKD-EPI: Chronic Kidney Disease Epidemiology Collaboration; MDRD: Modification of Diet in Renal Disease.

* The GFR estimating equations used by most clinical laboratories are the CKD-EPI formula and the MDRD formula. These formulas give similar results at low eGFR ranges, and either may be used to monitor kidney function in the later stages of CKD.

¶ Prior to starting an asymptomatic patient with eGFR <5 mL/min/1.73 m² on chronic dialysis, a physical examination should be performed to ensure the patient is not excessively diuresed. In addition, at least one repeat serum creatinine measurement should be obtained to rule out a temporary decrease in kidney function.

Δ While symptoms of kidney disease may be present in some patients with eGFR >15 mL/min/1.73 m², they usually can be managed by medical therapy; dialysis is rarely required.

◊ Uremic symptoms are often nonspecific and may be due to other conditions or to side effects of medications commonly used in patients with CKD. Refer to UpToDate content on indications for initiation of dialysis in CKD for details.

§ Acute dialysis is sometimes indicated for the urgent/emergent treatment of hyperkalemia. Refer to UpToDate content on treatment and prevention of hyperkalemia in adults for details.

¥ Most patients with eGFR ≥10 mL/min/1.73 m² and symptoms attributed to impaired kidney function can be treated medically. Among patients who have persistent, disabling uremic symptoms despite a creatinine-based eGFR that is consistently ≥10 mL/min/1.73 m², it is reasonable to obtain a more accurate estimate of GFR. Refer to UpToDate content on assessment of kidney function for details.

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Indications for initiation of maintenance dialysis in chronic kidney disease