End-stage renal failure - initiating chronic dialysis
Context
- Applies to CKD stage 5 (eGFR <15) approaching or reaching end-stage kidney failure
- Decision is symptom/complication-driven, not a fixed eGFR trigger - a major shift from older "start at eGFR X" teaching
Epidemiology
- Leading causes of ESKD requiring dialysis in Australia: diabetic nephropathy, glomerulonephritis, hypertensive nephrosclerosis, polycystic kidney disease
- Aboriginal and Torres Strait Islander peoples - markedly higher incidence and often younger age at initiation
Pathophysiology of end-stage disease
- Progressive nephron loss -> failure of excretory (uraemic toxins), regulatory (fluid, acid-base, electrolytes) and endocrine (EPO, vitamin D activation) kidney functions
- Uraemic syndrome once GFR critically low - pericarditis, encephalopathy, platelet dysfunction, refractory fluid overload/acidosis/hyperkalaemia
Planning triggers (well before dialysis needed)
- Referral to nephrology at eGFR ~15-20 (or earlier if rapid decline) for education, modality choice, and access planning
- Arteriovenous fistula creation ~6 months before anticipated need (matures over weeks-months) - avoid unnecessary venepuncture/cannulation of the non-dominant forearm once CKD advanced
Indications to start dialysis - AEIOU refractory to medical therapy
Indications to actually start dialysis - the "AEIOU" refractory to medical therapy
| Acidosis | Severe, refractory to bicarbonate |
| Electrolytes | Hyperkalaemia refractory to medical therapy |
| Intoxication | Dialysable toxin (not the primary CKD indication) |
| Overload | Fluid overload/pulmonary oedema refractory to diuretics |
| Uraemia | Symptomatic - pericarditis, encephalopathy, uraemic bleeding, refractory nausea |
- No fixed eGFR threshold mandates dialysis in an asymptomatic patient - the IDEAL trial found no benefit to early (eGFR ~10-14) over late (~5-7) planned start when initiation is otherwise symptom-guided
- Dialysis can be safely deferred in symptom-free patients even with eGFR persistently <10, provided close monitoring
Modality choice - patient-centred, made well ahead of need
Modality choice - patient-centred, made well ahead of need
- Haemodialysis (in-centre or home) vs peritoneal dialysis vs conservative (non-dialysis) care vs pre-emptive transplantation (best outcome if a suitable donor available)
- Conservative care is a legitimate, actively chosen pathway in the frail/elderly with high comorbidity burden - dialysis does not clearly extend survival or improve quality of life in this group
Access
- AV fistula preferred over graft or central venous catheter - lowest infection/thrombosis rate, best longevity
- Catheter access carries the highest infection and mortality risk - used when fistula/graft not ready or PD not chosen
Pre-dialysis optimisation
- Manage anaemia (ESA + iron), CKD-MBD (phosphate, vitamin D, PTH), acidosis (oral bicarbonate), volume and BP
- Vaccinate (hepatitis B series - essential before haemodialysis exposure), dietary counselling (K+, phosphate, protein, fluid)
- Advance care planning discussion - especially where conservative care is being considered
Complications on dialysis
- Cardiovascular disease is the leading cause of death on dialysis, not kidney failure itself
- Dialysis-associated: catheter-related bacteraemia, access thrombosis/steal syndrome (fistula), PD peritonitis
- Amyloidosis (beta-2 microglobulin) with long-term dialysis
Outcomes
- Median survival on dialysis is substantially shorter than age-matched controls, more so in older/comorbid patients
- Transplantation (especially pre-emptive/living donor) offers the best long-term survival and quality of life of any ESKD treatment
- Conservative care - survival in frail elderly patients can approach that of dialysis once comorbidity burden is high, with fewer hospitalisations and better preserved quality of life
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