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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Dialysis Main Page

Patient Information



Peritoneal Dialysis



Chronic kidney disease (CKD) prevalence has an increased rate worldwide due to increased prevalence of diabetes mellitus and hypertension as the leading causes of CKD, increasing life expectancy, and aging of the populations. On the other hand, acute kidney injury requires renal replacement therapy in certain circumstances. Dialysis is an intervention aiming to substitutes for solutes and removing extra fluids to help or substitute the failing kidneys. It is considered as a renal replacement therapy method which is indicated in certain condition depending on severity and chronicity of the underlying condition. In acute setting, refractory increased electrolytes and fluid overload are the most common indications for dialysis. eGFR is the determining factor to initiate dialysis in chronic kidney disease however, uremic symptoms, presence of comorbidities, and nutritional status are important factors influencing nephrologist's judgement to consider early versus late dialysis. In 2010, it is estimated that 2.3-7.1 million patients died of end stage renal disease (ESRD) without having access to dialysis. In 2010, 2.62 million people received dialysis worldwide and the need for dialysis was projected to double by 2030.[1] Timely initiating dialysis could save lives, prevent complications, and decrease comorbidities. Patients should be educated about the process and goals of this method of treatment.


There are two main types of dialysis, hemodialysis and peritoneal dialysis. The mode of dialysis should be selected based on patients preference, chronicity of disease, underlying disease, comorbidities, and availability of the modality.

Peritoneal dialysis
Continuous ambulatory
peritoneal dialysis (CAPD)
Continuous cyclic
peritoneal dialysis (CCPD)
peritoneal dialysis (IPD)


The decision to initiate dialysis or hemofiltration in patients with renal failure can depend on several factors. The following factors are the most important aspects that nephrologists consider in every patient individually to initiate dialysis.

Uremic Symptoms

The following table describe the uremic symptoms and signs according to National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guidelines.[2][3]

Uremia manifestations
Symptoms Signs
Fatigue Seizure/change in seizure threshold
Lethargy Amenorrhea
Confusion Reduced core body temperature
Anorexia Protein-energy wasting
Alteration in smelling and tasting senses Insulin resistance
Cramps Heightened catabolism
Restless legs Serositis (pleuritis, pericarditis)
Sleep disturbances Hiccups
Pruritus Platelet dysfunction

Nutritional Status

Nutritional status of CKD patients should be assessed frequently. Many factors could be considered as indicator, such as normalized protein equivalent of nitrogen appearance (nPNA), subjective global assessment (SGA), assessment of body composition by bioelectrical impedance analysis (BIA), lean body mass, and serum albumin level. Deterioration of nutritional status which is considered as protein energy malnutrition, resistant to dietary supplementation is an indication for dialysis.[4][5][6][7][8]


Conditions like volume overload and heart failure may result in clinical deterioration in CKD patients regardless of eGFR level. Accordingly, these conditions must be assessed in every patients for early diagnosis and dialysis initiation.[9][10][11]

Metabolic Derangements

Persistent metabolic and electrolyte derangements despite medical therapy are conditions that may require incident dialysis in acute settings. They include hyperkalemia, metabolic acidosis, and dialysable drug intoxications, such as lithium or aspirin toxicity.

National Kidney Foundation Recommendation

Summary the recommendation from NKF KDOQI 2015 guidelines for dialysis indicates the following indications for initiating dialysis:

  • Signs and/or symptoms associated with uremia
  • Evidences of protein-energy wasting
  • Inability to safely manage metabolic abnormalities and/or volume overload with medical therapy


  1. Liyanage T, Ninomiya T, Jha V, Neal B, Patrice HM, Okpechi I, Zhao MH, Lv J, Garg AX, Knight J, Rodgers A, Gallagher M, Kotwal S, Cass A, Perkovic V (May 2015). "Worldwide access to treatment for end-stage kidney disease: a systematic review". Lancet. 385 (9981): 1975–82. doi:10.1016/S0140-6736(14)61601-9. PMID 25777665.
  2. Slinin Y, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Wilt TJ (November 2015). "Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline". Am. J. Kidney Dis. 66 (5): 823–36. doi:10.1053/j.ajkd.2014.11.031. PMID 26498415.
  3. "KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update". Am. J. Kidney Dis. 66 (5): 884–930. November 2015. doi:10.1053/j.ajkd.2015.07.015. PMID 26498416.
  4. Cano F, Azocar M, Cavada G, Delucchi A, Marin V, Rodriguez E (January 2006). "Kt/V and nPNA in pediatric peritoneal dialysis: a clinical or a mathematical association?". Pediatr. Nephrol. 21 (1): 114–8. doi:10.1007/s00467-005-2048-9. PMID 16208532.
  5. Moreau-Gaudry X, Jean G, Genet L, Lataillade D, Legrand E, Kuentz F, Fouque D (November 2014). "A simple protein-energy wasting score predicts survival in maintenance hemodialysis patients". J Ren Nutr. 24 (6): 395–400. doi:10.1053/j.jrn.2014.06.008. PMID 25194620.
  6. Segall L, Moscalu M, Hogaş S, Mititiuc I, Nistor I, Veisa G, Covic A (March 2014). "Protein-energy wasting, as well as overweight and obesity, is a long-term risk factor for mortality in chronic hemodialysis patients". Int Urol Nephrol. 46 (3): 615–21. doi:10.1007/s11255-014-0650-0. PMID 24474221.
  7. Beberashvili I, Azar A, Sinuani I, Kadoshi H, Shapiro G, Feldman L, Averbukh Z, Weissgarten J (March 2013). "Comparison analysis of nutritional scores for serial monitoring of nutritional status in hemodialysis patients". Clin J Am Soc Nephrol. 8 (3): 443–51. doi:10.2215/CJN.04980512. PMC 3586967. PMID 23411424.
  8. Zhang R, Ren YP (October 2012). "Protein-energy wasting and peritoneal function in elderly peritoneal dialysis patients". Clin. Exp. Nephrol. 16 (5): 792–8. doi:10.1007/s10157-012-0631-5. PMID 22526487.
  9. Crews DC, Scialla JJ, Boulware LE, Navaneethan SD, Nally JV, Liu X, Arrigain S, Schold JD, Ephraim PL, Jolly SE, Sozio SM, Michels WM, Miskulin DC, Tangri N, Shafi T, Wu AW, Bandeen-Roche K (May 2014). "Comparative effectiveness of early versus conventional timing of dialysis initiation in advanced CKD". Am. J. Kidney Dis. 63 (5): 806–15. doi:10.1053/j.ajkd.2013.12.010. PMC 4117406. PMID 24508475.
  10. Crews DC, Scialla JJ, Liu J, Guo H, Bandeen-Roche K, Ephraim PL, Jaar BG, Sozio SM, Miskulin DC, Tangri N, Shafi T, Meyer KB, Wu AW, Powe NR, Boulware LE (February 2014). "Predialysis health, dialysis timing, and outcomes among older United States adults". J. Am. Soc. Nephrol. 25 (2): 370–9. doi:10.1681/ASN.2013050567. PMC 3904572. PMID 24158988.
  11. Kazmi WH, Gilbertson DT, Obrador GT, Guo H, Pereira BJ, Collins AJ, Kausz AT (November 2005). "Effect of comorbidity on the increased mortality associated with early initiation of dialysis". Am. J. Kidney Dis. 46 (5): 887–96. doi:10.1053/j.ajkd.2005.08.005. PMID 16253729.

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