When Do You Need Dialysis? The Signs That Decide It

Sean Hashmi
2 days ago
2 min read

The short answer

There is no eGFR number that automatically puts you on dialysis. The 2024 review of dialysis in JAMA states plainly that no recommended eGFR threshold exists for starting, and that the timing should be decided together by you and your clinician. What actually drives the decision is what your body is doing: uremia symptoms such as nausea and appetite loss, fluid you can no longer clear, acid building up in the blood, and a potassium that keeps climbing. Stage 5 kidney failure does begin below an eGFR of 15 under the KDIGO 2024 guideline, but that is a wide zone rather than a switch, and people live below it for years without dialysis.

What we cover

Why no single eGFR value starts dialysis, and why the direction of your last three or four readings carries the real signal. (JAMA, 2024)
Why one reading moves on its own, after a day of dehydration, a large protein meal, a recent infection, or a change of lab.
The four things clinicians actually watch: uremia symptoms, fluid overload, metabolic acidosis, and rising potassium. (JAMA, 2024)
What the IDEAL randomized trial found in 828 adults when it compared starting early against waiting. (New England Journal of Medicine, 2010)
Why preparing early helps enormously while starting early does not, and why an arm fistula takes months to be ready.
Why a rushed start usually means a neck catheter, and what that costs in infection risk. (JAMA, 2024)
How SGLT2 inhibitors, blood pressure control, and treating the underlying cause bend the slope of kidney decline. (New England Journal of Medicine, 2020 and 2023)
Why choosing not to start dialysis is a legitimate decision for some older adults living with other serious illness.

Timestamps

00:00 Why no eGFR number starts dialysis

02:31 Why one reading can mislead you

03:37 The four signs that actually start dialysis

05:27 The IDEAL trial: early versus late start

08:18 Preparing early versus starting early

09:03 Fistula versus catheter

10:12 Bending the slope of kidney decline

12:26 Which of the three are you

References

Flythe JE, Watnick S. Dialysis for Chronic Kidney Failure: A Review. JAMA. 2024;332(18):1559-1573. doi:10.1001/jama.2024.16338
Cooper BA, Branley P, Bulfone L, et al. A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis. New England Journal of Medicine. 2010;363(7):609-619. doi:10.1056/NEJMoa1000552
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International. 2024;105(4S):S117-S314. PMID 38490803
Heerspink HJL, Stefansson BV, Correa-Rotter R, et al. Dapagliflozin in Patients with Chronic Kidney Disease. New England Journal of Medicine. 2020;383(15):1436-1446. doi:10.1056/NEJMoa2024816
The EMPA-KIDNEY Collaborative Group. Empagliflozin in Patients with Chronic Kidney Disease. New England Journal of Medicine. 2023;388(2):117-127. doi:10.1056/NEJMoa2204233

When to see a doctor

If you develop breathlessness at rest, swelling that keeps getting worse, nausea that will not settle, or you are told your potassium is high, contact your kidney team promptly rather than waiting for your next scheduled visit.

Get my free kidney health guide: guides.selfprinciple.org/kidney

This content is for educational purposes only and is not medical advice. Always consult your healthcare provider for individual care. The views expressed are Dr. Hashmi's own and do not represent his employer.