'Ideal Criteria' for Starting Chronic Hemodialysis: Numbers, Symptoms or an Alerting 'Traffic Light' System
Nephron Clinical Practice
The Question One of the most demanding questions in nephrology practice and teaching is 'When shall this patient need hemodialysis treatment?' If the patient has some absolute (such as pericarditis, treatment-resistant fluid overload or pulmonary edema, uremic encephalopathy, significant bleeding, persistent severe nausea and vomiting) or relative (such as severe and persistent anorexia, fatigue or pruritus) indications for starting dialysis  , the answer is rather straightforward. However,
... n a stable and symptom-free patient when someone (either the patient or a student) is asking the exact time dialysis will be started, there is no clear-cut answer. Patients, students and even policymakers are asking this question as 'the simplest question of nephrology', but for a clinician it is still a challenging one even after 50 years of hemodialysis treatment. From Opinion to Guideline Recommendations In the early times of chronic hemodialysis programs, a major focus for a physician was selection of the most suitable patient when 'faced with 10 candidates for a single place '  . This was a question of life or death and decision analyses involved not only medical conditions but Abstract A definite criteria for starting chronic hemodialysis treatment is still lacking even after 50 years of regular hemodialysis treatment. Although none of the current guidelines have designated a certain glomerular filtration rate (GFR) level to start hemodialysis, most favor an 'earlier' start after GFR falls below 15 ml/min. Hence, since mid-1990s, more patients have initiated dialysis on higher GFR levels. Most of the observational data and one randomized trial, however, failed to find any benefit, but even harm, from an earlier start in various patient populations including the healthiest groups. This paper has reviewed the available evidence and criticized the use of only 'GFR level' in the absence of a validated method in end-stage kidney disease patients. A new patient scoring system mimicking traffic lights was proposed in which patients were placed into green, yellow or red zones for deciding the ideal time to start hemodialysis. This scoring system should include not only validated GFR criteria but also a wide set of demographic and clinical parameters.