When to Start Dialysis Shouldn't Be a Lab Test Decision—Here's What Doctors Are Changing

When advanced kidney disease progresses toward failure, the decision to start dialysis shouldn't be based on lab numbers alone—it should center on how you actually feel and what matters most to your life. A major clinical review published in Nature emphasizes that dialysis initiation must be guided by clinical symptoms and shared decision-making with patients, rather than relying solely on laboratory values. This represents a meaningful shift in how nephrologists (kidney specialists) approach one of the most consequential decisions in kidney disease management.

Why Lab Numbers Alone Miss the Full Picture?

For decades, doctors have relied heavily on blood test results—specifically measures of kidney function—to determine when patients should begin dialysis. But this approach overlooks a critical reality: two patients with identical lab values can feel completely different. One might experience severe fatigue, nausea, and loss of appetite (signs of uremia, or buildup of waste products in the blood), while another feels relatively well. The new guidance recognizes that uraemic symptoms—the actual physical signs that your kidneys can no longer filter waste effectively—should take priority over biological parameters when making this decision.

This patient-centered approach acknowledges that kidney disease doesn't progress in a straight line for everyone. Some people decline rapidly; others plateau for years. Some have significant heart disease or other serious conditions that complicate treatment decisions. A one-size-fits-all approach based on test results alone ignores these individual differences.

What Does "Shared Decision-Making" Actually Mean for Patients?

Shared decision-making means your nephrologist discusses the benefits and potential harms of starting dialysis versus continuing without it, taking your preferences and quality of life into account. This conversation should happen well before you reach kidney failure, during what doctors call advanced chronic kidney disease (CKD) stages G4 and G5—when kidney function is severely reduced but not yet completely gone.

For some patients, particularly older individuals or those with multiple serious health conditions, conservative kidney management might be the better choice. This approach emphasizes managing symptoms without starting dialysis or transplantation, focusing instead on maintaining the best possible quality of life. The key is that this decision is made together, with full understanding of what each path involves.

Three Treatment Pathways at Advanced Kidney Disease

• Pre-emptive Transplantation: Receiving a kidney transplant before dialysis becomes necessary offers the best outcomes, including better quality of life, superior kidney graft function, improved survival rates, and lower overall costs compared to transplantation after time on dialysis.
• Home Dialysis Options: Peritoneal dialysis and home hemodialysis should be encouraged over in-center hemodialysis because they provide better quality of life, lower morbidity and mortality rates, and reduced costs.
• Conservative Management: For select patients, particularly those who are older or have substantial comorbidities, symptom management without kidney replacement therapy may be preferred, with focus on maintaining dignity and comfort.

What Happens to Kidney-Protective Medications at Advanced Stages?

One critical point that often gets overlooked: just because your kidneys are failing doesn't mean you stop taking medications that protect them. Nephroprotective therapies—drugs that help slow kidney disease progression and prevent heart problems—should continue through CKD stages G4 and G5. These medications might delay or even prevent the development of uremic syndrome and its serious consequences, including cardiovascular disease. They can also benefit patients who eventually need transplantation or dialysis.

Additionally, nutritional care becomes increasingly important at advanced stages. Low-protein diets can help mitigate uremic symptoms, reducing the buildup of waste products that make you feel sick.

The Global Access Problem That Complicates Everything

While these new guidelines represent progress in patient-centered care, they highlight a sobering reality: considerable disparities in access to kidney disease treatment exist worldwide, especially in low- and middle-income countries. Not everyone has access to pre-emptive transplantation, home dialysis options, or even in-center dialysis. This means tailored strategies are needed to make advanced kidney disease management feasible and equitable across different regions and healthcare systems.

The shift toward symptom-based, patient-centered decision-making in advanced kidney disease reflects a growing recognition that kidney failure isn't just a medical problem—it's a life problem. The goal is to help you live as well as possible, for as long as possible, in a way that aligns with your values and priorities.