# Plan kidney replacement before deciding to start it

Planning and starting are separate decisions. Use kidney-function trajectory, kidney-failure risk, symptoms, preferences and expected benefit to discuss pre-emptive transplantation, home or facility dialysis and active conservative kidney management. Arrange individualized access planning and preserve veins when appropriate; a fistula is not automatic for every person with G4 CKD. Dialysis starts for a composite clinical assessment, including otherwise uncontrolled fluid, electrolyte or acid–base complications, uremic symptoms or progressive nutritional deterioration, not an isolated eGFR of 15. IDEAL did not find a survival benefit from a planned earlier eGFR-based start. Emergencies require action regardless of the planning timeline.

[KDIGO 2024 CKD](https://kdigo.org/guidelines/ckd-evaluation-and-management/) · [IDEAL, Cooper et al., 2010 — PubMed](https://pubmed.ncbi.nlm.nih.gov/20581422/)

Andrew Bland, MD, FACP, FAAP