Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:

Subscribers log in here

Indications for initiation of dialysis in chronic kidney disease


The decision to initiate dialysis in a patient with chronic kidney disease (CKD) involves the consideration of subjective and objective parameters by the physician and the patient. There are no absolute laboratory values that indicate a requirement to begin dialysis. The decision is partly based on the patient’s perception of his or her quality of life and anxiety about starting a complex, potentially lifelong therapy. In addition, the nephrologist’s perception about the patient’s state of health, decline of kidney function, and potential hazards of therapy influence the timing of initiation of renal replacement therapy. In short, the decision of when to start dialysis is clearly one of the most difficult decisions that both the patient and the nephrologist must make.

This topic reviews the clinical indications for the initiation of chronic dialysis.

The selection of dialysis modality is discussed separately (see "Dialysis modality and patient outcome" and "Choosing a modality for chronic peritoneal dialysis"). Considerations regarding transplantation are also discussed separately. (See "Evaluation of the potential renal transplant recipient" and "Patient survival after renal transplantation".)


There are a number of clinical indications to initiate dialysis in patients with CKD. These include [1-3]:

Pericarditis or pleuritis (urgent indication)

Progressive uremic encephalopathy or neuropathy, with signs such as confusion, asterixis, myoclonus, wrist or foot drop, or, in severe cases, seizures (urgent indication)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2014. | This topic last updated: May 22, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
  1. Pendse S, Singh A, Zawada E. Initiation of dialysis. In: Handbook of Dialysis, 4th ed., Daugirdas JT, Blake PG, Ing TS (Eds), Lippincott Williams & Wilkins, Philadelphia 2007.
  2. K/DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 2006; 47(Suppl 4):S1.
  3. Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
  4. Balogun SA, Balogun RA, Evans J. Age-related differences in renal function at onset of renal replacement therapy in chronic kidney disease stage 5 patients. QJM 2006; 99:595.
  5. Acchiardo SR, Moore LW, Latour PA. Malnutrition as the main factor in morbidity and mortality of hemodialysis patients. Kidney Int Suppl 1983; 16:S199.
  6. Lowrie EG, Lew NL. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990; 15:458.
  7. Owen WF Jr, Lew NL, Liu Y, et al. The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med 1993; 329:1001.
  8. Comorbid conditions and correlations with mortality risk among 3,399 incident hemodialysis patients. Am J Kidney Dis 1992; 20:32.
  9. Hakim RM. Initiation of dialysis. In: Advances in Nephrology, Grunfeld JP, Back JF, Kreis H, Maxwell MH (Eds), Mosby Yearbook, Chicago 1994. Vol 23.
  10. Misra M, Nolph KD, Khanna R, et al. Retrospective evaluation of renal kt/V(urea) at the initiation of long-term peritoneal dialysis at the University of Missouri: relationships to longitudinal nutritional status on peritoneal dialysis. ASAIO J 2003; 49:91.
  11. Hakim RM, Levin N. Malnutrition in hemodialysis patients. Am J Kidney Dis 1993; 21:125.
  12. Hakim RM, Lazarus JM. Initiation of dialysis. J Am Soc Nephrol 1995; 6:1319.
  13. Ikizler TA, Greene JH, Wingard RL, et al. Spontaneous dietary protein intake during progression of chronic renal failure. J Am Soc Nephrol 1995; 6:1386.
  14. Hakim RM, Lazarus JM. Biochemical parameters in chronic renal failure. Am J Kidney Dis 1988; 11:238.
  15. Maroni BJ, Steinman TI, Mitch WE. A method for estimating nitrogen intake of patients with chronic renal failure. Kidney Int 1985; 27:58.
  16. Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. Am J Kidney Dis 2000; 35:S1.
  17. Pupim LB, Kent P, Caglar K, et al. Improvement in nutritional parameters after initiation of chronic hemodialysis. Am J Kidney Dis 2002; 40:143.
  18. Mehrotra R, Berman N, Alistwani A, Kopple JD. Improvement of nutritional status after initiation of maintenance hemodialysis. Am J Kidney Dis 2002; 40:133.
  19. Tang SC, Ho YW, Tang AW, et al. Delaying initiation of dialysis till symptomatic uraemia--is it too late? Nephrol Dial Transplant 2007; 22:1926.
  20. Bonomini V, Feletti C, Scolari MP, Stefoni S. Benefits of early initiation of dialysis. Kidney Int Suppl 1985; 17:S57.
  21. Korevaar JC, Jansen MA, Dekker FW, et al. When to initiate dialysis: effect of proposed US guidelines on survival. Lancet 2001; 358:1046.
  22. Hakim RM. Quand commencer la dialyze: Les bases de la decision. In: Actualites Nephrologiques, Funck-Brentano JL, Back JF, Kreis H, Grunfeld JP (Eds), Jean Hamburger, Hospital Necker, Medecines – Sciences/Flammarion, Paris 1993.
  23. Traynor JP, Simpson K, Geddes CC, et al. Early initiation of dialysis fails to prolong survival in patients with end-stage renal failure. J Am Soc Nephrol 2002; 13:2125.
  24. Kazmi WH, Gilbertson DT, Obrador GT, et al. Effect of comorbidity on the increased mortality associated with early initiation of dialysis. Am J Kidney Dis 2005; 46:887.
  25. Rosansky SJ, Eggers P, Jackson K, et al. Early start of hemodialysis may be harmful. Arch Intern Med 2011; 171:396.
  26. Susantitaphong P, Altamimi S, Ashkar M, et al. GFR at initiation of dialysis and mortality in CKD: a meta-analysis. Am J Kidney Dis 2012; 59:829.
  27. Cooper BA, Branley P, Bulfone L, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med 2010; 363:609.
  28. Lameire N, Van Biesen W. The initiation of renal-replacement therapy--just-in-time delivery. N Engl J Med 2010; 363:678.
  29. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl 2013; 3:5.
  30. Chiu K, Alam A, Iqbal S. Predictors of suboptimal and crash initiation of dialysis at two tertiary care centers. Hemodial Int 2012; 16 Suppl 1:S39.