Indications for initiation of dialysis in chronic kidney disease

INTRODUCTION — This topic reviews the indications for chronic dialysis for patients with end-stage kidney disease (ESKD). Indications for acute dialysis, as well as other issues related to the care of the patient with chronic kidney disease (CKD), including timely referral to a nephrologist, consideration of conservative kidney management, evaluation for kidney transplantation, and preparations for dialysis are discussed elsewhere:

●(See "Kidney replacement therapy (dialysis) in acute kidney injury in adults: Indications, timing, and dialysis dose", section on 'Urgent indications'.)

●(See "Overview of the management of chronic kidney disease in adults".)

●(See "Kidney palliative care: Conservative kidney management".)

●(See "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient".)

●(See "Evaluating patients for chronic peritoneal dialysis and selection of modality".)

GENERAL PRINCIPLES

Optimal timing of dialysis — For patients with CKD, the decision to start chronic dialysis is made in collaboration between the nephrologist and patient. For patients with advanced CKD, advantages of chronic dialysis include potential improvement in uremic symptoms and volume overload (if present) that are not responding to medical management, and/or a lower risk of developing acute, life-threatening complications of end-stage kidney disease (ESKD). Disadvantages of chronic dialysis include the risks of dialysis-associated complications and a lifetime of episodic discomfort and inconvenience.

The optimal time to initiate chronic dialysis is when the nephrologist and patient agree that the overall benefits of kidney replacement therapy likely outweigh the risks and substantial burdens.

Unplanned dialysis initiation in patients with CKD is associated with increased hospitalizations, morbidity, and mortality [1]. Thus, planning for dialysis or its alternative, conservative kidney management, 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. (See "Overview of the management of chronic kidney disease in adults".)

Calculating the estimated glomerular filtration rate — Kidney function assessed by estimated glomerular filtration rate (eGFR) is an important factor in determining when patients with advanced CKD should initiate dialysis. The GFR estimating equations used by most clinical laboratories are the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula and the Modification of Diet in Renal Disease (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. In one study that included 409 patients starting dialysis, the mean eGFR at dialysis initiation was 6 mL/min/1.73 m² according to both estimating equations [2]. (See "Assessment of kidney function", section on 'Assessment of GFR'.)

No absolute indication for dialysis based on eGFR — There is no minimum estimated glomerular filtration rate (eGFR) that provides an absolute indication to begin dialysis in the absence of symptoms. Some patients, especially those who are young and have few comorbidities, may remain relatively asymptomatic despite an eGFR <10 mL/min/1.73 m².

Although there is no minimum eGFR that defines an absolute need for dialysis, we and most nephrologists initiate dialysis when the eGFR decreases below 5 mL/min/1.73 m² (see 'eGFR <5 mL/min/1.73 m2' below). Most patients will be symptomatic at such a low eGFR. However, even in the absence of symptoms, at such a low eGFR there is increased risk of unplanned, emergent dialysis initiation [3].

In the Initiating Dialysis Early and Late (IDEAL) study, the only trial in which survival was compared between patients initiating dialysis at two different thresholds of eGFR, survival was comparable between the two groups [4]. In this study, 828 patients with an eGFR between 10 and 15 mL/min/1.73 m² (as determined by the Cockcroft-Gault equation) were randomly assigned to start dialysis early (when the eGFR was 10 to 14 mL/min/1.73 m²) or late (when the eGFR was 5 to 7 mL/min/1.73 m²). Using the CKD-EPI equation, this would correspond to approximately 8 to 13 mL/min/1.73 m² for the early-start group versus 3 to 5 mL/min/1.73 m² for the late-start group. The median time to the initiation of dialysis was two and seven months in the early- and late-start groups, respectively. At a median follow-up of nearly four years, the survival was similar between the groups (62 and 63 percent), as were the number of cardiovascular events, infections, and dialysis complications.

However, these results do not imply that the initiation of dialysis can be delayed until the eGFR is between 5 and 7 mL/min/1.73 m² in all patients. The design of the IDEAL study permitted clinicians to initiate dialysis based on the presence of uremic symptoms and volume overload as well as on the eGFR. As a result, 76 percent of patients assigned to the late-start arm initiated dialysis earlier than planned. This resulted in a mean eGFR of 10 mL/min/1.73 m² (7 mL/min/1.73 m² with the CKD-EPI equation) at dialysis initiation for the late-start group, which was only 2 mL/min/1.73 m² less than the mean eGFR at dialysis initiation for the early-start group (12 mL/min/1.73 m², or 9 mL/min/1.73 m² with the CKD-EPI equation). Approximately 88 percent of all enrolled patients had initiated dialysis with an eGFR of approximately 7 mL/min/1.73 m² (CKD-EPI) or more, either because of symptoms or enrollment in the early dialysis arm.

Thus, in the absence of indications, patients with a CKD-EPI eGFR above 10 mL/min/1.73 m² do not require dialysis, although many will be placed on dialysis prior to the eGFR falling below 5 mL/min/1.73 m².

The IDEAL study was rapidly accepted in the nephrology community. After publication of the IDEAL trial, observational data showed that, compared with prepublication, fewer patients had an early-start of dialysis postpublication (34 versus 39 percent) [5].

INDICATIONS FOR INITIATION OF CHRONIC DIALYSIS — The decision of when to initiate dialysis remains complex. Our approach is based upon the presence of end-stage kidney disease (ESKD)-related signs and symptoms, the estimated glomerular filtration rate (eGFR), and, in some patients, the rate of eGFR decline (algorithm 1). These factors must be considered together. There is variability in the timing of dialysis initiation between patients because uremic symptoms are often nonspecific and because eGFR is an imperfect measure of kidney function. (See "Assessment of kidney function", section on 'Estimation of GFR'.)

Our general approach is largely consistent with the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines [6], the 2014 Canadian Society of Nephrology guidelines [7], the European guidelines [8], and the 2015 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines [9].

The indications for starting dialysis are the same for patients starting hemodialysis and peritoneal dialysis. Logistics surrounding the initiation of peritoneal dialysis are unique, however. (See 'Patients planning peritoneal dialysis' below.)

eGFR >15 mL/min/1.73 m2 — We generally do not initiate chronic dialysis for patients with eGFR >15 mL/min/1.73 m², even when they have possible symptoms related to ESKD. 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, and dialysis is rarely required. When patients with eGFR >15 mL/min/1.73 m² present with symptoms of ESKD, other causes should be excluded or treated before considering dialysis. Specific signs and symptoms are discussed below. (See 'Specific signs and symptoms' below.)

eGFR 5 to 15 mL/min/1.73 m2 — We follow patients with eGFR 5 to 15 mL/min/1.73 m² closely. After shared decision-making, we initiate dialysis in those who have developed uremia-related signs and symptoms that are refractory to medical therapy. An important exception is patients with uremic pericarditis, pleuritis, or encephalopathy whose goals of care align with dialysis; such patients should be started on dialysis without delay. (See 'Absolute indications for dialysis' below.)

For asymptomatic patients with eGFR >5 mL/min/1.73 m², dialysis initiation based solely on eGFR criteria does not improve outcomes. (See 'No absolute indication for dialysis based on eGFR' above.)

Absolute indications for dialysis — Absolute indications to start dialysis include the following rare but life-threatening complications of advanced CKD [10-12]:

●Uremic pericarditis or pleuritis.

●Uremic encephalopathy – True uremic encephalopathy (ie, significant alterations in cognitive function in a patient without other causes) is a rare condition that usually does not occur with eGFR >5 mL/min/1.73 m². Emergent dialysis is indicated if it does occur, as dialysis is the primary treatment. Because uremic encephalopathy can be difficult to distinguish from other causes, dialysis is sometimes initiated in patients with advanced CKD and no other obvious cause of toxic-metabolic encephalopathy. If the encephalopathic symptoms do not improve with dialysis, it can generally be discontinued.

Not only are these conditions treated by dialysis, but they are clear indicators that the patient has progressed to ESKD.

Other uremic signs and symptoms — Among patients with eGFR 5 to 15 mL/min/1.73 m² without uremic pericarditis, pleuritis, or encephalopathy, other uremic signs and symptoms are relative indications for dialysis.

Approach to uremic symptoms — Uremic symptoms are often nonspecific and may be due to other conditions or to side effects of medications commonly used in patients with CKD. Our general approach to determining whether such symptoms should be an indication for chronic dialysis varies by eGFR:

●eGFR ≥10 mL/min/1.73 m² – Most patients with eGFR ≥10 mL/min/1.73 m² and symptoms attributed to impaired kidney function can be treated medically. Symptoms due to advanced kidney dysfunction are usually not disabling until the eGFR is <10 mL/min/1.73 m² [4].

Among patients who have persistent uremic symptoms despite an eGFR that is consistently ≥10 mL/min/1.73 m², a nuclear determination of GFR or a 24-hour urine for measurement of urea and creatinine clearance may be performed to provide a more accurate estimate of the GFR. While the GFR estimation equations have been found to be reliable for clinical purposes in the vast majority of patients, occasionally eGFR may not accurately reflect actual GFR. As an example, among patients who have extremely low muscle mass, the eGFR calculated by CKD-EPI and MDRD may overestimate the true GFR. (See "Assessment of kidney function", section on 'Confirmation of eGFR (when needed)'.)

For those who have GFR confirmed ≥10 mL/min/1.73 m², we intensify efforts to identify and treat nonuremic causes of symptoms. If no other causes are identified and the symptoms persist, it is reasonable to proceed with dialysis.

●eGFR <10 mL/min/1.73 m² – As the eGFR declines below 10 mL/min/1.73 m², patients may develop symptoms of ESKD that no longer can be treated medically and require dialysis [8].

These eGFR thresholds are not absolute. The severity of symptoms varies substantially among patients. Younger patients and patients without other comorbid conditions tend to tolerate lower eGFR levels without developing as many symptoms.

Specific signs and symptoms — Common signs and symptoms that may provide an indication for dialysis initiation, but are not considered absolute indications, include:

●Declining nutritional status

●Persistent or difficult-to-treat volume overload

●Fatigue and malaise

●Mild cognitive impairment

Our general approach to symptoms is discussed above (see 'Approach to uremic symptoms' above). These specific indications are discussed individually below.

●Declining nutritional status – We generally initiate dialysis in patients with an eGFR <15 mL/min/1.73 m² who have anorexia, nausea, weight loss, or poor caloric intake that cannot be attributed to causes other than kidney function impairment and that cannot be adequately treated by conservative measures. These symptoms are common reasons to start chronic dialysis, and nutritional status may improve after dialysis initiation [13,14].

With declining eGFR, symptoms of anorexia and weight loss are usually the first uremic symptoms to appear. Loss of appetite for meat is a frequent early symptom and sign [15-18]. In a study of 90 patients with CKD who received no dietary intervention, a direct correlation was noted between the dietary protein intake and the creatinine clearance [16]:

•1.1 g/kg per day at a clearance above 50 mL/min/1.73 m²

•0.85 g/kg per day between 25 and 50 mL/min/1.73 m²

•0.70 g/kg per day between 10 and 25 mL/min/1.73 m²

•0.54 g/kg per day below 10 mL/min/1.73 m²

After development of anorexia and weight loss, patients may then develop early morning nausea, followed by frequent nausea and vomiting.

The development of anorexia and malnutrition may be insidious and often may be due to causes other than uremia. Our approach to the patient with advanced CKD and declining nutritional status is outlined below:

•Evaluation and assessment – The evaluation of anorexia requires a careful history (including dietary protein intake), physical examination, and laboratory studies. It can be difficult to obtain an accurate history about poor appetite. Sometimes, patients and family members realize that anorexia is a key factor in the decision about dialysis, and they may not provide accurate information in order to delay or avoid dialysis.

Following the patient's edema-free weight is helpful, especially when followed over a number of months. A decline in serum albumin also signifies worsening nutritional status. Some nephrologists may also follow urinary nitrogen excretion as a marker of protein intake although this is rarely done in clinical practice.

•Exclusion and treatment of other causes – Clinicians must be aware of a number of other potential causes of anorexia and/or nausea. As an example, diabetic gastroparesis should be diagnosed, evaluated, and treated, if present. (See "Diabetic autonomic neuropathy of the gastrointestinal tract", section on 'Management'.)

A number of medications that are started at the time of kidney failure may also cause nausea. As an example, iron supplements frequently cause gastric symptoms. Phosphate binders, alkali replacement in the form of sodium citrate or sodium bicarbonate, and some antihypertensive medications may cause nausea. Changing to intravenous iron and alternative phosphate binders and antihypertensive medications may alleviate the nausea.

●Persistent volume overload – Persistent volume overload poorly responsive to diuretic management is another indication for the initiation of chronic dialysis. Sodium retention worsens as kidney function deteriorates. Volume overload can lead to refractory hypertension and recurrent hospital admissions for congestive heart failure. Diuretics should not be withheld to prevent a rise in the blood urea nitrogen (BUN) and serum creatinine levels. Instead, the patient should be diuresed to euvolemia or at least to a volume status that, in the clinician's judgment, is well tolerated by the patient, and the BUN and serum creatinine levels evaluated at this volume status. Dialysis is appropriate if the target volume status cannot be achieved by optimizing diuretic therapy. (See "Overview of the management of chronic kidney disease in adults", section on 'Volume overload'.)

●Fatigue and malaise – Fatigue and malaise are common in patients with impaired kidney function, even at relatively early stages of CKD [19]. However, these symptoms often have causes other than impaired kidney function. It is important for the clinician to rule out other etiologies of fatigue and malaise, such as sedating medications, anemia, or depression. (See "Treatment of anemia in nondialysis chronic kidney disease".)

If a thorough workup does not identify other causes of persistent fatigue and malaise, dialysis may improve symptoms. Improvements in fatigue after dialysis initiation, if they occur, are generally more pronounced in younger patients without comorbidities. Observational data suggest that chronic dialysis usually does not improve quality of life in older patients [20,21].

The association between declining kidney function and fatigue is illustrated by a study of patients with autosomal dominant tubulointerstitial kidney disease, which is typically an asymptomatic cause of CKD. Fatigue was reported by 15 percent of unaffected family members, 20 percent of affected individuals with stage 2 CKD, 45 percent of those with stage 3 CKD, and 55 percent with stage 4 CKD [19].

●Mild cognitive impairment – It is usually difficult to attribute cognitive impairment to advanced CKD. As GFR worsens in older patients with CKD, the development of mild cognitive impairment unrelated to lower GFR is common. It is vital to exclude progressive dementia in patients with advanced CKD since patients with significant cognitive impairment may not tolerate and are unlikely to benefit from dialysis. (See "Evaluation of cognitive impairment and dementia" and "Kidney palliative care: Conservative kidney management", section on 'Ideal candidates for CKM'.)

Dialysis initiation only rarely improves cognitive impairment. However, for selected patients who are interested in pursuing it, a three- to four-week trial of dialysis may be reasonable to see if it improves mental faculties. Alternatively, in the patient with dementia, conservative management of kidney failure without dialysis may be indicated. (See "Kidney palliative care: Withdrawal of dialysis", section on 'Indications for withdrawal of dialysis'.)

Refractory acidosis, hyperkalemia, and hyperphosphatemia — Although dietary interventions and/or medical therapies are often effective in the prevention of severe metabolic acidosis, hyperkalemia, and hyperphosphatemia, the ongoing presence of these acid-base and electrolyte abnormalities increases the rationale for starting dialysis.

Patients with advanced CKD may develop marked acidosis that is difficult to treat medically. Patients may not be able to tolerate large enough oral doses of sodium bicarbonate or sodium citrate to reach target serum bicarbonate values. (See "Pathogenesis, consequences, and treatment of metabolic acidosis in chronic kidney disease", section on 'Therapeutic approach'.)

Hyperkalemia may also develop and become persistent, despite dietary restriction and medical management. (See "Treatment and prevention of hyperkalemia in adults", section on 'Patients who can have the serum potassium lowered slowly'.)

Hyperphosphatemia may require dietary restriction and/or the initiation of binders (see "Management of hyperphosphatemia in adults with chronic kidney disease", section on 'Patients with nondialysis chronic kidney disease'). Hyperphosphatemia usually does not occur until eGFR <15 mL/min/1.73 m² and often occurs close to the need for dialysis.

eGFR <5 mL/min/1.73 m2 — Most patients with eGFR < 5 mL/min/1.73 m² will have uremic signs and symptoms that are difficult to treat medically. Our approach to patients with this degree of kidney function impairment, assuming they have not elected to pursue conservative kidney management, is as follows:

●For patients with absolute or relative indications, we start dialysis. (See 'Absolute indications for dialysis' above and 'Specific signs and symptoms' above and 'Refractory acidosis, hyperkalemia, and hyperphosphatemia' above.)

●For asymptomatic patients with CKD who have eGFR <5 mL/min/1.73 m², we suggest initiating chronic dialysis rather than delaying dialysis until the occurrence of absolute or relative indications. However, prior to starting an asymptomatic patient on chronic dialysis, we perform a physical examination to ensure they are not excessively diuresed. We also obtain at least one repeat measurement of serum creatinine to rule out a temporary decrease in kidney function.

We believe that at such a markedly reduced eGFR, the risks of an asymptomatic patient requiring emergent dialysis initiation or having severe complications of ESKD are unacceptably high without elective dialysis initiation.

There is a theoretical concern that the increasing use of newer, creatinine-based GFR estimating equations that do not account for Black race may lead to inappropriately early dialysis initiation in some asymptomatic Black patients with advanced CKD. At eGFRs in the 5 mL/min/1.73 m² range, the CKD-EPI creatinine equation without a race variable (adopted in 2021) tends to underestimate GFR by approximately 1 mL/min/1.73 m² in Black patients. This amount is small in absolute terms but represents approximately 20 percent of residual kidney function. Although no convincing data suggest that the widespread adoption of these newer creatinine equations has led to an earlier initiation of dialysis in Black patients, it is reasonable for the nephrologist to discuss this issue with an asymptomatic Black patient with advanced CKD before starting dialysis based solely on eGFR criteria. Shared decision making in this setting may lead some patients to pursue additional assessment of GFR. (See "Assessment of kidney function", section on 'Assessment of GFR'.)

SPECIAL POPULATIONS

Patients with rapid kidney function decline — It may be reasonable to initiate dialysis in some asymptomatic patients with estimated glomerular filtration rate (eGFR) ≥5 mL/min/1.73 m² who have rapidly declining kidney function. In such patients, delaying dialysis may increase the risk of emergent dialysis initiation in the future or the development of severe complications of end-stage kidney disease (ESKD).

The loss of kidney function is variable and may occur quickly in up to 20 percent of patients. As an example, in a national cohort study of 23,349 United States veterans requiring dialysis, 4804 (21 percent) of the patients experienced an abrupt decline as their kidney failure progressed [22]. In the Chronic Renal Insufficiency Cohort (CRIC) Study, 8.5 percent had an abrupt decline leading to dialysis. Risk factors for decline included cardiovascular disease, diabetes, and cancer [23].

Older patients — Indications for dialysis in older patients are the same as in the general population with CKD. There is no evidence that initiating dialysis earlier in older patients is beneficial [4]. As in other patient groups, treatment with dialysis versus conservative therapy leads to longer survival though several studies have shown no survival benefit in older patients with high comorbidities [24]. In older patients with many comorbid conditions and decreased quality of life, careful discussions should take place regarding the benefits and hardships of dialysis. (See "Kidney palliative care: Conservative kidney management", section on 'Offering CKM' and "Maintenance dialysis in the older adult", section on 'Decision to initiate maintenance dialysis'.)

Comorbid conditions — The timing of dialysis initiation is not altered by comorbid conditions. There is no evidence that patients with diabetes [4,25] or cardiovascular disease [4] benefit from earlier initiation of dialysis. However, patients who have comorbid conditions are at higher risk of unplanned, emergent dialysis initiation [3,26]. Such patients should be followed more closely for the need for dialysis.

Patients with life-shortening comorbidities (eg, end-stage heart failure or end-stage liver failure), frailty, significant functional or cognitive impairment, and/or who live in long-term care facilities are unlikely to gain survival and are at risk for hospitalizations after initiation of dialysis. Such patients are ideal candidates for nondialytic (ie, conservative) management of their kidney disease. (See "Kidney palliative care: Conservative kidney management", section on 'Ideal candidates for CKM'.)

Patients planning peritoneal dialysis — The indications for starting dialysis are the same for patients starting peritoneal dialysis and hemodialysis. However, the timing of initiation of peritoneal dialysis is a complex decision that requires coordination between the nephrologist, the patient, and the dialysis center that will perform the training. Unlike a permanent hemodialysis access, which is preferably created weeks to months before dialysis is started, a peritoneal dialysis catheter is generally placed only 10 to 14 days before it is used. After the catheter is placed, however, the patient must be trained to perform dialysis, which is difficult to accomplish if they are uremic. As a result, among patients who require the acute initiation of chronic dialysis, hemodialysis is often initiated first using a temporary hemodialysis catheter, even if peritoneal dialysis is the preferred modality over the long term.

The increasing availability of urgent-start peritoneal dialysis (defined as initiation of peritoneal dialysis less than two weeks after peritoneal dialysis catheter is placed), as well as earlier peritoneal dialysis catheter placement in selected patients, may ultimately reduce the number of patients who require hemodialysis before starting peritoneal dialysis. (See "Urgent-start peritoneal dialysis" and "Evaluating patients for chronic peritoneal dialysis and selection of modality", section on 'Timing of catheter placement'.)

OTHER CONTRIBUTING FACTORS

●Attitude of the nephrologist – The attitude of the nephrologist strongly influences the time of initiation of dialysis, and there are substantial differences in practice patterns between individual physicians, regions, and countries [27-30]. In a retrospective study of patients starting dialysis in 2006 (n = 83,621) in the US Renal Data System (USRDS), 16 percent of patients initiated dialysis with an estimated glomerular filtration rate (eGFR) ≥15 mL/min/1.73 m², and 48 percent of patients initiated dialysis with an eGFR of >10 mL/min/1.73 m². Factors associated with early start included physician graduation from nondomestic medical schools and less provider nephrologist experience [28]. Another study of USRDS data showed that dialysis was initiated earlier in some geographic regions of the United States (in order of earlier start of dialysis): Mountain regions, Midwest, Pacific, Mid-Atlantic, South, and New England [29]. One study suggested that salaried nephrologists at Veterans Affairs (VA) facilities were less likely to initiate dialysis among patients with an eGFR ≥10 mL/min/1.73 m² compared with non-VA nephrologists (who usually received increased financial compensation for each patient on dialysis). This study could not exclude confounding factors [30].

For the nephrologist, starting a patient on dialysis at a given eGFR, regardless of symptoms, is often the easiest approach, particularly if the threshold eGFR for dialysis initiation is >10 mL/min/1.73 m².

Patients who have a very low eGFR (ie, <10 mL/min/1.73 m²) and are not on dialysis require very close follow-up, which is usually labor intensive for the nephrologist. In contrast, the delivery of care in outpatient dialysis units is usually well coordinated and very easy for a nephrologist to administer.

Attitudes regarding the initiation of dialysis have changed over time. Previous clinical guidelines supported the decision to initiate patients at a higher eGFR than is generally recommended today [31,32].

●Timing of referral to a nephrologist – The timing of referral of patients with CKD to a nephrologist may have an impact on the timing of dialysis initiation. Referral occurs at variable levels of kidney function but often late in the course of progressive kidney failure, just before or even after the onset of symptomatic uremia. Late nephrology referral is a risk factor for unplanned dialysis initiation [3]

Early referral is preferred because it affords the opportunity to assess the rate of progression of kidney disease, to exclude any reversible causes of a declining GFR, and to permit close follow-up and adequate advance dialysis planning. It may also improve patient outcomes. This is discussed in detail separately. (See "Overview of the management of chronic kidney disease in adults", section on 'Referral to nephrologists'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Peritoneal dialysis (The Basics)" and "Patient education: Hemodialysis (The Basics)")

●Beyond the Basics topics (see "Patient education: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics)" and "Patient education: Hemodialysis (Beyond the Basics)" and "Patient education: Peritoneal dialysis (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Optimal timing of dialysis – The optimal time to initiate chronic dialysis is when the nephrologist and the patient with advanced chronic kidney disease (CKD) agree that the overall benefits of kidney replacement therapy likely outweigh the risks and substantial burdens. There is no minimum estimated glomerular filtration (eGFR) that provides an absolute indication to begin dialysis in the absence of symptoms. Some patients, especially those who are young and have few comorbidities, may remain relatively asymptomatic despite an eGFR <10 mL/min/1.73 m². (See 'General principles' above.)

●Indications for chronic dialysis – The decision of when to initiate dialysis remains complex. This is because uremic symptoms are often nonspecific and because the eGFR is an imperfect measure of kidney function. Our general approach is based upon the presence of signs and symptoms related to end-stage kidney disease (ESKD) and the eGFR (algorithm 1). These factors are considered together as follows:

•eGFR >15 mL/min/1.73 m² – We generally do not initiate chronic dialysis for such patients, even when they have possible symptoms related to ESKD. 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, and dialysis is rarely required. (See 'eGFR >15 mL/min/1.73 m2' above.)

•eGFR 5 to 15 mL/min/1.73 m² – We follow such patients closely and initiate dialysis in those who develop uremia-related signs and symptoms that are refractory to medical therapy. An important exception is patients who have uremic pericarditis, pleuritis, or encephalopathy; such patients should be started on dialysis without delay. Most patients with eGFR ≥10 mL/min/1.73 m² and symptoms attributed to impaired kidney function can be treated medically. However, when other causes have been ruled out and medical management optimized, persistent malnutrition, volume overload, fatigue or malaise, and acid-base or electrolyte abnormalities are relative indications for dialysis. (See 'eGFR 5 to 15 mL/min/1.73 m2' above.)

•eGFR <5 mL/min/1.73 m² – Most patients with eGFR <5 mL/min/1.73 m² have uremic signs and symptoms and/or acid-base/electrolyte abnormalities that will require treatment with chronic dialysis. For asymptomatic patients with CKD who have eGFR <5 mL/min/1.73 m², we suggest initiating chronic dialysis rather than delaying dialysis until the occurrence of absolute or relative indications (Grade 2C). We believe that at such a markedly reduced eGFR, the risks of an asymptomatic patient requiring emergent dialysis initiation or having severe complications of ESKD are unacceptably high without elective dialysis initiation. (See 'eGFR <5 mL/min/1.73 m2' above.)

●Patients with rapid kidney function decline – It may be reasonable to initiate dialysis in some asymptomatic patients with eGFR ≥5 mL/min/1.73 m² who have rapidly declining kidney function. In such patients, delaying dialysis may increase the risk of emergent dialysis initiation in the future or the development of severe complications of ESKD. (See 'Patients with rapid kidney function decline' above.)

●Patients planning peritoneal dialysis – The indications for starting dialysis are the same for patients starting peritoneal dialysis and hemodialysis. However, the timing of initiation of peritoneal dialysis is a complex decision that requires coordination between the nephrologist, the patient, and the dialysis center that will perform the training. (See 'Patients planning peritoneal dialysis' above.)