Visual summary
Choose around the patient’s clinical needs and daily life, prepare early, and start for a composite clinical indication rather than an isolated eGFR.
Text version
Planning is not a start order
Begin education and access/transplant planning before crisis. KDIGO suggests preparation when eGFR is <15–20 or 2-year KRT risk exceeds 40%. Actual initiation uses symptoms, nutrition, refractory fluid/electrolyte problems, goals, and kidney function together.
Hemodialysis: intermittent clearance
Blood passes through an extracorporeal dialyzer. In-center treatment supplies staff and infrastructure but imposes a schedule and travel. Home HD can change frequency and flexibility, with training, suitable space, and support requirements. Discuss post-treatment fatigue and access care.
Peritoneal dialysis: daily home treatment
Dialysate dwells in the abdomen and removes solute and fluid through the peritoneum. Manual exchanges or a cycler require training, storage, aseptic technique, and a workable home routine. Residual urine output and peritoneal transport influence the prescription.
Include transplant and conservative care
Assess transplant eligibility early, including living-donor possibilities when appropriate. Comprehensive conservative care actively treats symptoms and complications without dialysis. Compare expected burdens and benefits with the person’s goals, rather than assuming one option fits every life expectancy.
Match the choice to daily life
Ask who can help, whether the patient can see and handle equipment, how work/travel fits, and what treatment burden is acceptable. Address housing or caregiver barriers directly. A plan may include assisted care or a later modality change.
Teach modality-specific escalation
Cloudy PD effluent or abdominal pain requires immediate contact and effluent testing for peritonitis. HD access bleeding, absent thrill, fever, chest pain, or severe post-treatment symptoms needs prompt assessment. Clearance numbers never replace symptom, nutrition, volume, and safety review.