Dialysis Initiation Strategies in Chronic Kidney Disease

Dialysis initiation in chronic kidney disease (CKD) represents a critical decision point that balances the risks of uraemic complications against the burdens of renal replacement therapy. Strategies broadly fall into two paradigms: biochemical threshold-driven initiation, usually guided by declining estimated glomerular filtration rate (eGFR), and symptom-driven initiation, which prioritises the emergence of clinical signs such as volume overload, refractory hypertension, anaemia or uraemic symptoms. Clinical factors including rate of eGFR decline, comorbidity profile, nutritional status, blood pressure control and local practice patterns all influence timing. Early initiation may prevent precipitate uraemia but carries risks of vascular access complications, reduced quality of life and higher health care costs. Conversely, very late initiation can expose patients to life-threatening metabolic derangements. Recent work has emphasised personalised decision making, integrating patient preferences, comorbid conditions and comprehensive assessment of uraemic burden rather than reliance on a fixed eGFR cut-off. This holistic approach has global relevance, informing guidelines in diverse health-care settings and aiming to optimise outcomes through tailored timing of dialysis initiation.

Research from Nature Portfolio

Recent research has delineated distinct risk profiles for patients commencing peritoneal dialysis (PD) at different stages. In a foundational cohort study, investigators identified that early mortality (within three months of PD start) was strongly associated with markers of inflammation, high serum phosphate and low serum albumin, while late mortality (beyond two years) was driven by cardiovascular disease and diabetes. These findings underscore the need for stratified management at initiation, with intensified nutritional and inflammatory risk assessment for those at highest early mortality risk, and vigilant cardiovascular monitoring for long-term survivors. Such insights advocate for risk-adapted protocols at the point of dialysis initiation.

Dialysis Initiation Strategies in Chronic Kidney Disease publication trend

The graph below shows the total number of articles in dialysis initiation strategies in chronic kidney disease across all publications each year (not limited to Nature Index journals).

Technical terms

Estimated glomerular filtration rate (eGFR): A calculated index of kidney function based on serum creatinine, age, sex and ethnicity, used to stage CKD.

Peritoneal dialysis (PD): A home-based modality in which the peritoneum acts as a semipermeable membrane to remove waste and excess fluid using dialysis solution.

Haemodialysis (HD): An extracorporeal modality where blood is filtered through an artificial membrane to eliminate toxins and fluid, typically in a clinic setting.

Uraemic burden: The cumulative physiological impact of retained solutes and toxins in advanced CKD, often assessed by biochemical markers and clinical symptoms.

Volume overload: Excess fluid accumulation in the body, manifesting as oedema or pulmonary congestion, and a key indication for dialysis initiation.

References

1. Patient characteristics and risk factors of early and late death in incident peritoneal dialysis patients. Scientific Reports (2016).
2. Timing and Modality of Kidney Replacement Therapy in Children and Adolescents. Kidney International Reports (2024).
3. Update of dialysis initiation timing in end stage kidney disease patients: is it a resolved question? A systematic literature review. BMC Nephrology (2023).
4. Dialysis Initiation in Patients With Chronic Coronary Disease and Advanced Chronic Kidney Disease in ISCHEMIA‐CKD. Journal of the American Heart Association (2022).