What are the indications for starting renal replacement therapy in patients with advanced CKD?

Renal replacement therapy (RRT) in patients with advanced chronic kidney disease (CKD) is considered based on several key indications ¹. Advanced CKD is typically defined as an estimated glomerular filtration rate (eGFR) of less than 15 ml/min/1.73 m², which is also referred to as kidney failure (GFR category G5) ².

Indications for initiating RRT include the impact of symptoms of uraemia on daily living, specific biochemical measures, or uncontrollable fluid overload ¹. RRT may also be considered at an eGFR of around 5 to 7 ml/min/1.73 m² even if there are no symptoms ¹.

Furthermore, RRT may be required for suspected complications of CKD, such as end-stage renal disease (ESRD), persistent hyperkalaemia, and persistent metabolic acidosis ³,⁴. Urgent RRT may be indicated if complications like refractory severe hyperkalaemia, metabolic acidosis, uraemia, fluid overload, or pulmonary oedema do not respond to medical management ⁵,⁶.

It is crucial that the decision to initiate dialysis is made jointly by the person (or, where appropriate, their family members or carers) and their healthcare team ¹. Before starting dialysis in response to symptoms, it is important to be aware that some symptoms may be caused by non-renal conditions ¹.