Renal Replacement Therapy — choice of modality and emergency initiation

Diagnosis: symptomatic stage 5 CKD (ESKD) — now needs RRT preparation and modality decision. The combination of uraemic symptoms (fatigue, anorexia, pruritus), fluid overload (oedema, raised JVP, breathlessness, hypertension), and biochemical derangement (anaemia, hyperkalaemia, acidosis, hyperphosphataemia, secondary hyperparathyroidism) at eGFR 11 mL/min establishes that he is at the symptomatic threshold for dialysis. He is NOT yet in an AEIOU emergency, so there is time for planned preparation.^[1]

Step 1 — Choose the modality, patient-centred. The four options are haemodialysis, peritoneal dialysis, kidney transplantation, and conservative care. He is an independent 68-year-old who wishes to work part-time, so transplant and home-based modalities are attractive. The decision should be made with the patient after multidisciplinary education.^[1]

• Kidney transplant offers the best survival and quality of life (Wolfe 1999: transplant halves mortality vs remaining on dialysis on the waiting list). Assess and list him pre-emptively (eGFR under 20). A living donor (spouse/family) should be sought; pre-emptive living-donor transplant is the goal.^[8]
• Haemodialysis — centre-based, 3 times/week, AV fistula best access; suits most adults but is disruptive to work.
• Peritoneal dialysis — home-based (APD overnight would preserve his work); gentler, preserves residual function; main risk peritonitis. A strong option for his lifestyle.
• Conservative care is less suitable here — he is independent and symptomatic with treatable uraemia.

Step 2 — Plan timely preparation (the ESKD ladder).^[7]

1. Vascular access now — an AV fistula (radio-cephalic or brachio-cephalic) needs 6-12 weeks to mature and should be created 6-12 months before anticipated dialysis; create it at this visit. Avoid subclavian catheters (central venous stenosis destroys future fistula veins). If he chooses PD, plan Tenckhoff catheter placement 2-4 weeks ahead.
2. Vaccination — hepatitis B series (double dose, confirm anti-HBs over 10 IU/L), pneumococcal, influenza, COVID-19 — before immunosuppression.
3. Transplant assessment — tissue typing, immunological (HLA, PRA, crossmatch), cardiac, infection (HBV/HCV/HIV/CMV/EBV/TB) and cancer screening; pre-emptive listing.
4. Manage complications now — IV iron + ESA for anaemia (target Hb 100-115 g/L); phosphate binders; cinacalcet/activated vitamin D for secondary hyperparathyroidism; oral sodium bicarbonate; antihypertensives (with dry-weight reduction in mind once dialysis starts).

Step 3 — When to initiate dialysis: planned vs urgent.^[6]

• Planned initiation is when symptoms of uraemia appear, typically at eGFR 5-10 mL/min — he is now at this threshold (symptomatic at eGFR 11). The IDEAL trial (Cooper 2010, NEJM) showed no survival or QoL benefit of initiating at eGFR 10-14 vs 5-7 — start for the patient, not for a number. Begin once access is mature.
• Urgent (emergency) initiation is for AEIOU: refractory Acidosis (pH under 7.1-7.15), refractory Electrolytes (K over 6.5 with ECG changes), dialysable Ingestion (lithium, salicylate, methanol, ethylene glycol, metformin), refractory fluid Overload, Uraemia (pericarditis, encephalopathy). He does not yet meet these — but a rising K or worsening acidosis would tip him over.

Step 4 — Shared decision and follow-up. Discuss goals, prognosis (annual dialysis mortality ~10-20%, dominated by cardiovascular disease; transplant halves this), and the burden vs benefit at his age and comorbidity. With his independence and preference to keep working, pursue transplant + a home modality (PD or home HD), with an AV fistula created now as a bridge and backup.