The decision to initiate dialysis for the management of end-stage renal disease (ESRD) usually depends on a combination of the pt's symptoms, comorbid conditions, and laboratory parameters. Unless a living donor is identified, transplantation is deferred by necessity, due to the scarcity of deceased donor organs (median waiting time, 3-6 years at most transplant centers). Dialytic options include hemodialysis and peritoneal dialysis (PD). Roughly 85% of U.S. pts are started on hemodialysis. All three forms of “renal replacement therapy” (RRT) require planning and preparation months to years before ESRD occurs; early referral to a nephrologist is thus critical for successful RRT.

Absolute indications for dialysis include severe volume overload refractory to diuretic agents, severe hyperkalemia and/or acidosis, severe encephalopathy not otherwise explained, and pericarditis or other serositis. Additional indications for dialysis include symptomatic uremia (Chap. 142 Chronic Kidney Disease and Uremia) (e.g., intractable fatigue, anorexia, dysgeusia, nausea, vomiting, pruritus, difficulty maintaining attention and concentration) and protein-energy malnutrition/failure to thrive without other overt cause. No absolute serum creatinine, blood urea nitrogen, creatinine or urea clearance, or glomerular filtration rate (GFR) is used as an absolute cutoff for requiring dialysis, although most individuals experience, or will soon develop, symptoms and complications when the GFR is below ∼10 mL/min. However, the “pre-emptive” initiation of dialysis in such pts, prior to the onset of clinical indications, does not improve outcomes in ESRD.