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Kidney Failure: When Should I Start Dialysis?
You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Kidney Failure: When Should I Start Dialysis?
Get the facts
- Start kidney dialysis early—before you have symptoms of kidney failure or your lab results show very poor kidney function.
- Don't start dialysis until you have symptoms or your lab results get worse.
Some people may decide not to treat their kidney failure with dialysis. This information is for people who have decided to have either hemodialysis or peritoneal dialysis but who aren't certain when they should start.
Key points to remember
- At a certain point in chronic kidney disease, you may need to have dialysis or a kidney transplant to live. This stage is called kidney failure. You reach it if you have constant fluid buildup and symptoms of too much urea and other wastes in your blood. You also have it if a measure of your kidney function (glomerular filtration rate, or GFR) falls too low.
- If you don't have symptoms yet, you may choose to start dialysis early or wait several months to a year to start it. Your doctor may recommend starting dialysis early when kidney function is better. Starting early may improve nutrition, reduce fluid in the body, and reduce your chance of going into the hospital for complications from kidney failure.
- You might decide to wait if you may be able to have a kidney transplant.
- Dialysis may help you feel better and live longer.
- Dialysis is time-consuming and can have serious side effects, such as low blood pressure and sudden cardiac arrest.
- It's not clear from studies that starting early will help you live longer than if you wait. How well you do on dialysis depends a lot on your age and any other health problems you may have.
- Thinking about starting dialysis may feel unsettling or even scary. If you decide to have it, dialysis will become a big part of your life. But you can take good care of yourself with a healthy diet and not smoking to help you get the most benefit from dialysis.
Having chronic kidney disease means that for some time your kidneys have not been working the way they should. Your kidneys have the important job of filtering your blood. They remove waste products and extra fluid and flush them from your body as urine. When your kidneys don't work right, wastes build up in your blood and make you sick. When kidney function falls below a certain point, it is called kidney failure.
A measure of your kidney function (glomerular filtration rate, or GFR) is used to show how well your kidneys work. (The GFR is calculated from the results of a creatinine test.) A GFR of 15 milliliters per minute (mL/min) or less shows that you have kidney failure.
As your kidney function gets worse, you may:
- Feel very tired.
- Feel nauseated or vomit.
- Have swelling from fluid building up in your body.
- Not feel hungry. You may lose weight.
- Have headaches.
- Have trouble thinking.
Kidney failure can cause serious heart, bone, and brain problems.
When you get close to kidney failure, your doctor will likely talk to you about your options. You may choose to treat your kidney failure with dialysis, to have a kidney transplant, or to have no treatment.
Dialysis is a process that filters your blood when your kidneys no longer can. It isn't a cure, but it can help you feel better and live longer. You can choose from two types of dialysis: hemodialysis (say "HEE-moh-dy-AL-uh-sus") and peritoneal dialysis (say "pair-uh-tuh-NEE-uhl dy-AL-uh-sus"):
A kidney transplant may be the best choice if you are otherwise healthy. With a new kidney, you would feel much better and be able to live a more normal life. But you may have to wait for a kidney that is a good match for your blood and tissue type. After the transplant, you would need to take medicines to keep your body from rejecting the new kidney. And you would need to see your doctor often and have blood tests to check how you're doing.
Not having dialysis or a transplant also is an option for people with kidney failure. Older adults or those with other serious health problems may decide instead to take medicines and make changes to their diet as their doctor recommends. Whatever you decide, discuss it with your family, friends, and medical team.
Deciding when to start dialysis can be confusing. Even the experts don't always agree on the best time to start or how long to wait. Waiting usually means 6 months to a year. But how long you can wait depends on several things, including your age and overall health aside from your kidneys.
Most people go on dialysis or get a kidney transplant when they have symptoms of kidney failure or when the main measure of their kidney function (glomerular filtration rate, or GFR) is less than 10 milliliters per minute (mL/min).
Results of studies don't agree
Studies don't agree on the best time to start:
- While some older studies showed that early dialysis lowers the risk of dying sooner, a more recent, high-quality study (a randomized controlled trial) found no difference in how long people lived between those who started dialysis early and those who waited.1
- Some studies have shown that early dialysis might increase the chance of dying sooner.2 But in those studies, the people who started early were often older men who were sicker because they had other health problems along with kidney failure.
Many things to consider
Your GFR isn't the only thing you and your doctor will look at in deciding when you should start dialysis. You will also consider:
- Whether you have swelling, nausea, or other symptoms of kidney failure.
- Your age.
- Your health aside from your kidney failure.
- How you feel—if you have the energy to do your daily activities.
- Your ability to make lifestyle changes and to commit time to dialysis.
Dialysis can help you feel better before you start to have bad symptoms. Some studies show that it also may improve your ability to get good nutrition and reduce the chances of going into the hospital from complications of kidney failure.2 It also may lower blood pressure in people who have high blood pressure.
Many experts recommend starting dialysis before you have any complications of kidney failure. That's because many of the complications can be deadly, such as not getting good nutrition, having too much fluid, or having too many wastes building up in your body.
Even if you don't start dialysis early, you may want to plan for dialysis if your kidney function is getting worse. You could have surgery months ahead of time to create a place, called an access, to take the blood from your body to the dialysis machine.
Dialysis—whenever it's started—can cause side effects. If you start early, you expose yourself for a longer time to the chance of side effects. Hemodialysis can cause low blood pressure and heart problems, such as sudden cardiac arrest. Peritoneal dialysis increases the risk of infection in the lining of your belly (peritonitis).
If you wait, you won't have as many limits on your time and lifestyle. Hemodialysis takes about 12 or more hours a week, usually in a dialysis center. Peritoneal dialysis needs to be done about 4 times a day, although it often can be done while you sleep.
Also, a recent study showed that starting dialysis early may not prolong your life. 1
If you decide to start dialysis early, it may help to know that it's common to feel a little overwhelmed and even scared at first. It's a big change in your life. But if you choose to start dialysis, you can make good choices in your lifestyle to help you get the most from it.
- Be careful about what you eat and drink when you're on dialysis. Your doctor will tell you how much fluid, protein, and salt (sodium) you can have. A dietitian can work with you to help you plan your meals.
- Exercise to help improve your energy. Work with your doctor to make sure that you are getting the right amount of exercise.
- Avoid substances that can harm your kidneys, such as alcohol, any kind of tobacco, or illegal drugs.
- Tell your doctor about all prescription medicines, over-the-counter medicines, and herbs that you are taking.
Compare your options
What is usually involved?
What are the benefits?
What are the risks and side effects?
- You have surgery to place an access in your blood vessels (usually in your lower arm) for hemodialysis. For peritoneal dialysis, you will have a catheter placed in your belly.
- It takes a lot of time—from several times a week to every day, depending on the type of dialysis.
- If you have hemodialysis at a center, you need to be able to get a ride or drive yourself to a center. (But in some cases you may be able to have hemodialysis at home.)
- If you have peritoneal dialysis, it can be done at home, usually while you are asleep. Hemodialysis can also be done at home. Because you can do it every day, you may not have to do it for as long as in-center hemodialysis.
- You will need to see your doctor often and have regular blood tests.
- You follow a diet that your doctor recommends. You may have to limit fluids you drink and not smoke.
- It may help you stay out of the hospital from complications of kidney failure.
- It may help you feel better.
- Hemodialysis can cause low blood pressure, muscle cramps, and irregular heartbeats. Peritoneal dialysis can cause an infection (peritonitis) of the lining of the belly. Some of these side effects can be dangerous.
- The catheter used for peritoneal dialysis and the access used for hemodialysis may need to be replaced if they become blocked or infected.
- You take medicines and follow a diet that your doctor recommends. You may have to limit fluids you drink. It's also important to not smoke and to follow your doctor's advice to help you put off having dialysis.
- Your doctor sees you often to see how well your kidneys are working. You will have blood and urine tests.
- You don't have to spend hours every week doing dialysis.
- You don't have the side effects and risks of hemodialysis, such as low blood pressure and heart problems, and infections in the access areas.
- You may not need to follow as strict a diet as you would on dialysis.
- You may have symptoms such as swelling, feeling very tired, and not thinking clearly.
- You could develop complications of kidney failure that could be deadly, such as inflammation of the sac around the heart, blood pressure problems, and seizures or coma.
Personal stories about considering early dialysis
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
For years now, I've been worrying about when I might need dialysis. Even though my labs results are still okay, and my doctor says I could wait a little longer, I don't feel that great. I'm tired all the time. My doctor agreed it would be okay for me to start dialysis now and see if I start to feel better.
Sandra, age 64
I'm just not ready to have dialysis. My test results are right on the edge, and I know I'd probably feel better if I did it. But I feel like having dialysis is giving up, like my life as I know it is over. It would depress me. I know I might have to do it sometime. But I'm just going to try to do everything my doctor asks me to so I can go as long as I can without it.
Fred, age 58
What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to have early dialysis
Reasons to wait to have dialysis
I'm ready to make lifestyle changes and commit time to dialysis.
I'm not ready to make lifestyle changes and commit time to dialysis.
I don't want to wait until I feel bad and maybe have complications.
I feel good now, so I think I can wait a while longer.
I'm worried because my lab results are getting worse.
My lab results aren't great, but I'm not worried about it right now.
I can accept how dialysis would change my life.
I'm afraid dialysis would change my life for the worse.
My other important reasons:
My other important reasons:
Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
Have early dialysis
Wait to have dialysis
What else do you need to make your decision?
Check the facts
Many kidney specialists recommend starting dialysis earlier rather than later to improve nutrition, reduce fluid in the body, and reduce the chance of going into the hospital for complications from kidney failure.
- True That's right. Many kidney specialists recommend starting earlier rather than later to improve nutrition, reduce fluid in the body, and reduce the chance of going into the hospital for complications from kidney failure.
- False Sorry, that's not right. Many kidney specialists do recommend starting earlier rather than later to improve nutrition, reduce fluid in the body, and reduce the chance of going into the hospital for complications from kidney failure.
- I'm not sure It may help to go back and read "Get the Facts." Many kidney specialists recommend starting earlier rather than later to improve nutrition, reduce fluid in the body, and reduce the chance of going into the hospital for complications from kidney failure.
Starting dialysis earlier might help me feel better.
Waiting to have dialysis will shorten my life.
- True Sorry, that's not right. A recent study showed no difference in survival between early and later dialysis.
- False That's right. A recent study showed no difference in survival between early and later dialysis.
- I'm not sure It may help to go back and read "Get the Facts." A recent study showed no difference in survival between early and later dialysis.
Decide what's next
Do you understand the options available to you?
Are you clear about which benefits and side effects matter most to you?
Do you have enough support and advice from others to make a choice?
How sure do you feel right now about your decision?
Use the following space to list questions, concerns, and next steps.
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
|Primary Medical Reviewer||Kathleen Romito, MD - Family Medicine|
|Specialist Medical Reviewer||Mitchell H. Rosner, MD - Nephrology|