Hemodialysis - Time to start dialysis

Guideline Organization

Recommendation (Evidence Level)

Evidence

Comments

CARI-Australia
2004

- Start dialysis when GFR <10ml/min/1.73m2 if there is evidence of uraemia or complications such as malnutrition. In occasional patients it may be necessary to initiate dialysis at a higher GFR. (Level III)
- If there is no evidence of uraemia or its complications, commence dialysis when GFR <6ml/min/1.73m2.(Level III)
- Start dialysis at first indication of malnutrition suspected to be due to uraemia and unresponsive to dietary intervention or correction of other reversible causes. (Level III)
- Absolute and relative indications are a historical concept…  (Level III)

Dialysis Guidelines.
Acceptance onto dialysis.
6. Level of renal function at which to initiate dialysis


Other criteria for starting dialysis

CSN-Canada
1999

- When GFR <120L/wk per 1.73m2 (12ml/min), look for symptoms or signs of uraemia or evidence of malnutrition. If uraemia or protein equivalent of nitrogen appearance (PNA = protein intake) <0.8g/kg per d or clinical malnutrition, recommend dialysis. (Level IV)
- If no evidence of uraemia or malnutrition, increase the frequency of observation to monthly and recommend dialysis when indicated. (Opinion)
- When GFR <60L/wk per 1.73m2 or 6ml/min, recommend initiation of dialysis. (Opinion)

Guideline 1.3 Initiation of dialysis
p 4-5 of 35 PDF pages.

GFR of 12 ml/min corresponds to Ccreat of 18ml/min or renal
Kt/V of 2.0

EBPG-Europe
2002

- Dialysis should be instituted whenever the GFR <15ml/min and there is one or more of the following: symptoms or signs of uraemia, inability to control hydration status or blood pressure or a progressive deterioration in nutritional status.  (Level C)
- Dialysis should be started before GFR ≤6ml/min/1.73m2 even if optimal pre-dialysis care has been provided and there are no symptoms. (Level C)
- High-risk patients e.g. diabetics may benefit from an earlier start. (Level C)
- To ensure that dialysis is started before GFR<6ml/min, clinics should aim to start at 8-10ml/min. (Level C)

1.3 When to start dialysis

KDOQI-US
2004

- Patients should be advised to initiate dialysis when renal Kt/V urea /week <2. (Opinion)
- The conditions that indicate dialysis as not yet necessary are: stable or increased edema) free body weight, complete absence of clinical signs or symptoms.
- If protein malnutrition develops and there is no apparent cause other than low nutrient intake, dialysis should be recommended. (Opinion)

Guideline 1:  When to Initiate Dialysis - Kt/Vurea Criterion

Renal Kt/V urea of 2.0 corresponds to a GFR of 10.5 ml/min/1.73m2

UK-Guidelines
2002

- Dialysis should be considered when the weekly CUrea < renal Kt/Vurea of <2.0 (GFR 14ml/min). Dialysis will be indicated if there is evidence of malnutrition or if symptoms interfere with quality of life. It is prudent to consider dialysis at this early stage in those with predictable steadily progressive renal failure as occurs in polycystic disease or glomerulonephritis. Those with stable renal function, however, may often be treated conservatively.

10. The management of patients approaching ESRD
p 165-166 of 204 PDF pages

Good practice