Deciding about dialysis

Deciding about dialysis is a treatment decision, not a disease or diagnosis. It usually comes up when the kidneys can no longer remove enough waste and extra fluid from the blood.

The decision is not based on one blood test alone. Your care team considers your symptoms, test trends, other health conditions, daily life, and treatment goals. Some people need dialysis urgently. Others have time to learn about their choices and prepare.

Dialysis performs part of the kidneys' filtering work. It does not restore normal kidneys or replace everything healthy kidneys do. Medicines and other care may still be needed.

The main choices may include:

• Hemodialysis, which filters blood through a machine
• Peritoneal dialysis, which uses the lining of the abdomen as a filter
• Kidney transplantation, for people who are eligible
• Conservative kidney management without dialysis or transplantation

Conservative kidney management is active medical care. It focuses on comfort, symptoms, medicines, practical support, and the person's priorities. It does not mean that care stops.

Healthy kidneys remove waste, balance water and minerals, and help control blood pressure. They also support red blood cell production and bone health. When kidney function becomes very low, waste or fluid may build up despite other treatment.

Hemodialysis moves blood through a filter outside the body. Blood is usually reached through an arteriovenous fistula, which joins an artery to a vein, or through a synthetic graft. A catheter placed in a large vein may be used when dialysis must begin before another form of access is ready. Hemodialysis can take place in a dialysis centre or, for some people, at home.

Peritoneal dialysis places cleansing fluid into the abdomen through a soft catheter. The peritoneum, the thin lining inside the abdomen, acts as the filter. The used fluid is drained and replaced. Exchanges may be done by hand during the day or by a machine overnight.

The timing of dialysis is based on the overall clinical picture. An estimated glomerular filtration rate, or eGFR, estimates how well the kidneys filter blood. A low eGFR is important, but it does not automatically set a start date.

Dialysis may be considered when kidney failure causes problems that cannot be managed adequately in other ways. Examples include persistent fluid overload, unsafe mineral levels, acid buildup, poor nutrition, or symptoms linked to waste buildup.

Planning can begin before dialysis is needed. This allows time for education, home assessment, transplant evaluation, and creation of dialysis access. Planning does not commit you to starting dialysis.

Dialysis can control some effects of kidney failure. It may reduce excess fluid, correct dangerous blood chemistry, and ease symptoms caused by waste buildup. In sudden kidney injury, dialysis may sometimes be temporary while the kidneys recover.

Treatment also has a substantial effect on daily life. Centre-based hemodialysis requires regular visits and recovery time. Home treatments require training, space for supplies, and support with routines. Diet, fluid intake, medicines, work, travel, and caring responsibilities may all be affected.

The likely benefits are not the same for everyone. Age alone does not decide whether dialysis is suitable. Other illnesses, frailty, mobility, thinking and memory, expected quality of life, and personal goals all matter.

Some people value treatment that may extend life even if it requires frequent procedures. Others place greater weight on remaining at home, avoiding hospital visits, or reducing treatment burden. There is no single choice that is right for every person.

A decision can often be reviewed as health or priorities change. In some situations, a time-limited trial of dialysis may be discussed. This involves agreeing on what treatment is meant to achieve and when its benefits and burdens will be reassessed.

If kidney failure is not controlled, related conditions can become serious. Uremia means illness caused by waste products building up in the body. It may be associated with nausea, loss of appetite, itching, confusion, inflammation around the heart, or worsening nutrition.

Other related problems include hyperkalemia, which is too much potassium in the blood; metabolic acidosis, which is excess acid in the blood; and fluid overload, which can affect breathing. These conditions are identified through symptoms, examination, and blood tests. They are not judged from eGFR alone.

Dialysis itself can cause difficulties. Hemodialysis may be associated with low blood pressure, cramps, access blockage, bleeding, or infection. Peritoneal dialysis can be complicated by catheter problems or peritonitis, an infection of the abdominal lining. Cloudy drained dialysis fluid or new abdominal pain needs prompt assessment.

Seek emergency help for severe trouble breathing, chest pain, a seizure, collapse, or new severe confusion. These symptoms have many possible causes but require immediate assessment.

Contact your kidney service promptly for rapidly increasing swelling, a major drop in urine output, repeated vomiting, worsening breathlessness, or new problems with dialysis access. Cloudy peritoneal dialysis fluid should also be reported immediately.

Changes such as gradually worsening itching, appetite, sleep, energy, or swelling usually need routine but timely review. Record when they began and how they affect normal activities.

Ask your kidney team what is driving the discussion. Useful questions include whether the kidney problem may improve, which findings would make dialysis necessary, and what may happen with or without dialysis.

Request education about every option that may reasonably apply to you. This can include different dialysis schedules, home treatment, transplantation, and conservative kidney management. Ask to meet the nurses or services that provide those forms of care.

Keep an up-to-date record of:

• Medicines, including non-prescription medicines and supplements
• Blood test trends, especially eGFR and potassium
• Changes in appetite, nausea, itching, swelling, breathing, and urine output
• Your priorities for independence, comfort, work, travel, and family life
• Questions you want answered before making a decision

Do not change fluid intake, salt, potassium, protein, or medicines without individual advice. Kidney diet needs are based on blood results, treatment type, nutrition, and remaining kidney function.

If dialysis may be needed later, ask when access planning or transplant assessment should begin. Protecting suitable arm veins may be important when a fistula is being considered. Your kidney team can give specific instructions.

You do not need to make the decision alone. With your permission, family members, carers, an interpreter, a social worker, or a supportive-care team can join discussions. You can also ask for information in writing and request another appointment before deciding when there is no emergency.

There is no home test that can confirm when dialysis should start. Home blood pressure and weight records may help if your care team has asked you to track them, but they do not replace clinical assessment and blood tests.

Does a low eGFR mean dialysis must start immediately?

Not by itself. The decision uses symptoms, examination findings, blood tests, nutrition, fluid balance, and whether other treatments are working. A rapidly changing result may need faster review than a stable result.

Can I choose the type of dialysis?

Often, yes. Medical needs, previous surgery, blood vessel health, home circumstances, support, and local service availability can affect which options are practical. Your preferences should be part of the decision.

Is conservative kidney management the same as doing nothing?

No. It includes treatment for symptoms and complications, medication review, emotional and practical support, and planning for future care. It does not use dialysis to replace kidney filtering.

Can dialysis be stopped after it starts?

Dialysis may stop if a sudden kidney injury improves. A person receiving long-term dialysis can also ask to review or stop treatment. This decision should include clear information, support for the person and family, and a plan to manage symptoms.

Can I change my mind?

Usually, yes. Choices can be revisited before treatment starts and while treatment is underway. An emergency may limit the time available, but the team should still explain what is happening and involve you as much as possible.