Dialysis
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# Overview
Chronic kidney disease (CKD) prevalence has an increased rate worldwide due to increased prevalence of diabetes mellitus and hypertension as the leading causes of CKD, increasing life expectancy, and aging of the populations. On the other hand, acute kidney injury requires renal replacement therapy in certain circumstances. Dialysis is an intervention aiming to substitutes for solutes and removing extra fluids to help or substitute the failing kidneys. It is considered as a renal replacement therapy method which is indicated in certain condition depending on severity and chronicity of the underlying condition. In acute setting, refractory increased electrolytes and fluid overload are the most common indications for dialysis. eGFR is the determining factor to initiate dialysis in chronic kidney disease however, uremic symptoms, presence of comorbidities, and nutritional status are important factors influencing nephrologist's judgement to consider early versus late dialysis. In 2010, it is estimated that 2.3-7.1 million patients died of end stage renal disease (ESRD) without having access to dialysis. In 2010, 2.62 million people received dialysis worldwide and the need for dialysis was projected to double by 2030. Timely initiating dialysis could save lives, prevent complications, and decrease comorbidities. Patients should be educated about the process and goals of this method of treatment.

# Classification
There are two main types of dialysis, hemodialysis and peritoneal dialysis. The mode of dialysis should be selected based on patients preference, chronicity of disease, underlying disease, comorbidities, and availability of the modality.

# Indications
The decision to initiate dialysis or hemofiltration in patients with renal failure can depend on several factors. The following factors are the most important aspects that nephrologists consider in every patient individually to initiate dialysis.

## Uremic Symptoms
The following table describe the uremic symptoms and signs according to National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guidelines.

## Nutritional Status
Nutritional status of CKD patients should be assessed frequently. Many factors could be considered as indicator, such as normalized protein equivalent of nitrogen appearance (nPNA), subjective global assessment (SGA), assessment of body composition by bioelectrical impedance analysis (BIA), lean body mass, and serum albumin level. Deterioration of nutritional status which is considered as protein energy malnutrition, resistant to dietary supplementation is an indication for dialysis.

## Comorbidities
Conditions like volume overload and heart failure may result in clinical deterioration in CKD patients regardless of eGFR level. Accordingly, these conditions must be assessed in every patients for early diagnosis and dialysis initiation.

## Metabolic Derangements
Persistent metabolic and electrolyte derangements despite medical therapy are conditions that may require incident dialysis in acute settings. They include hyperkalemia, metabolic acidosis, and dialysable drug intoxications, such as lithium or aspirin toxicity.

## National Kidney Foundation Recommendation
Summary the recommendation from NKF KDOQI 2015 guidelines for dialysis indicates the following indications for initiating dialysis:
- Signs and/or symptoms associated with uremia
- Evidences of protein-energy wasting
- Inability to safely manage metabolic abnormalities and/or volume overload with medical therapy