Update 9/16/14: When you are done reading this, please check out the comments at the bottom of this post. They are excellent.
I found this fascinating question and answer in “Ask the Doctor”
My dad has stage 5 kidney disease. GFR was 13 a month ago, and 10 about 2 weeks ago. His doctor is looking at the creatinine level and saying that he has about a year to go before starting dialysis, however we should look into the transplant option. His creatinine level is around 5.2. Looking at the GFR, I feel like there is not much time, however the doc seems to think he’s OK for another year. What tests do you use to determine the amount of time left on your own kidneys without dialysis or transplant?
Dialysis is not based on any specific number. Dialysis is based on having specific symptoms that can be treated by starting dialysis treatments. This is commonly based on discussion between your father and the nephrologist. There is discussion about the risks of treatment and the burdens of starting dialysis care versus the benefits of relieving symptoms associated with chronic kidney disease (CKD). Only the nephrologist can make recommendations and your father must decide about whether he is willing to endure the burdens of care.
The answer is short and to-the-point but it leaves much to the imagination about when to begin dialysis. At first, I wanted to just re-blog the post but I’m concerned that the answer is too brief and not very informative. It is a “safe” answer in that it basically says, “well, it’s relative. Only the nephrologist knows when to begin dialysis. The doctor will tell you when to begin and then you can decide to do it or not.”
Granted this guy is probably older (since he’s someone’s father and they are asking for him) but I take issue with the “whether he is willing to endure the burdens of care”. What “burdens”? Dialysis for older folks is probably more difficult than younger people but you can’t just assume he’s old and frail. Some older people are pretty sturdy! Anyway, I digress. I need to return to the question of “when to begin”.
In my case, I pushed dialysis off for at least a year but not through any particular method like diet or such. I just kept pushing the limits until the doctor finally declared, “It’s time.” He said my creatinine wasn’t bad but my BUN (Blood-urea-nitrogen) was getting to a level of being dangerous. So, I began. If you’ve been reading my blog, you probably know my experience with “Dialysis and the First Stick” or “Dialysis and the First Stick – more“.
So, the answer to the question of when to begin is relative is correct. It really depends on the factors involved. Some people are informed early enough while they are in CKD (Chronic Kidney Disease) and before ESRD (End Stage Renal Disease) to know what to expect. Then, there are those who find out in the emergency room that they must start dialysis now. Some doctors will tell their that dialysis is an eventuality if that’s the case but not all doctors will be that informative. I’m not sure why but that’s the way it is.
If you are CKD and haven’t started dialysis, you will probably be told your “numbers” based on the labs. When I was in CKD, the number to watch was creatinine. THe, like I write above, it was the BUN. The doctor was watching a combination of the numbers but I was only told about those two. Recently, the GFR (Glomerular filtration rate) is the popular measure, However, when you read about it, you’ll note it involves the Serum creatinine level and that is central to the GFR calculation. Most people I speak with who are CKD and and pre-dialysis are watching their GFR. Unusually when it gets to about 20 percent (in other words, their kidneys are functioning at about 20 percent of “normal”), their doctors are telling them to get ready for dialysis.
In the case above, I’m a bit suspicious of those numbers and the doctors estimate of “a year to go”. A GFR of 13 is very low because it’s under 20. I personally think dialysis will be called for in less than a year. It’s more like immediately. But, the doctor is the expert, not me. However, the doctor could be wrong and this man could end up in the ER and begin dialysis much sooner than a year. Knowing he has a year, they should begin preparation for dialysis including getting an access.
That’s about it. When to begin dialysis is “relative”. It depends on when you transition from CKD to ESRD. If you have some notice that it’s pending you have a chance to get prepared for it by having an access made or (“Dialysis and the Access“) so you don’t have to put up with a chest catheter. Talk to your nephrologist and make sure you understand what he/she is watching for and how score in those measurements.