‘Ideal Criteria’ for Starting Chronic Hemodialysis: Numbers, Symptoms or an Alerting ‘Traffic Light’ System?

Abstract

A definite criteria for starting chronic hemodialysis treatment is still lacking even after 50 years of regular hemodialysis treatment. Although none of the current guidelines have designated a certain glomerular filtration rate (GFR) level to start hemodialysis, most favor an ‘earlier’ start after GFR falls below 15 ml/min. Hence, since mid-1990s, more patients have initiated dialysis on higher GFR levels. Most of the observational data and one randomized trial, however, failed to find any benefit, but even harm, from an earlier start in various patient populations including the healthiest groups. This paper has reviewed the available evidence and criticized the use of only ‘GFR level’ in the absence of a validated method in end-stage kidney disease patients. A new patient scoring system mimicking traffic lights was proposed in which patients were placed into green, yellow or red zones for deciding the ideal time to start hemodialysis. This scoring system should include not only validated GFR criteria but also a wide set of demographic and clinical parameters.

The spectrum of kidney dysfunction requiring chronic dialysis therapy: Implications for clinical practice and future clinical trials

“…ESKD, also referred to as chronic kidney disease Stage 5 requiring dialysis (CKD Stage 5D), denotes the presence of a single, final stage of kidney failure accompanied by clinical signs and symptoms for which chronic dialysis therapy is required to sustain life. 5 Indeed, when a diagnosis of ESKD is considered, the primary focus properly shifts from GFR to clinical and biochemical domains inclusive of volume overload and impaired solute clearance. 5 Notwithstanding the primary importance of clinical manifestations in the decision of initiating chronic dialysis therapy, disregarding endogenous kidney function-predominantly when hemodialysis (HD) is prescribed-is a lost opportunity for recognizing the diversity of this "last stage" disease and, with that, a lost opportunity to personalized care.…”

“…5 Indeed, when a diagnosis of ESKD is considered, the primary focus properly shifts from GFR to clinical and biochemical domains inclusive of volume overload and impaired solute clearance. 5 Notwithstanding the primary importance of clinical manifestations in the decision of initiating chronic dialysis therapy, disregarding endogenous kidney function-predominantly when hemodialysis (HD) is prescribed-is a lost opportunity for recognizing the diversity of this "last stage" disease and, with that, a lost opportunity to personalized care. We performed a scoping review of the literature pertaining to the management of ESKD with intermittent HD.…”