The Changing Standards for Dialysis Initiation

Modern nephrology has moved away from the outdated textbook rule of “start dialysis at creatinine 707 μmol/L (8 mg/dL).” This change reflects medicine’s shift toward personalized treatment decisions rather than rigid numerical thresholds.

Why was this standard removed?

1. Creatinine is imperfect: While important, it’s an unreliable standalone marker of kidney function
2. Misses complications: Doesn’t reflect critical clinical factors like:

• Fluid overload
• Electrolyte imbalances
• Uremic symptoms

1. Risk of mistiming: Strict adherence could mean:

• Starting too late (when complications are severe)
• Starting too early (wasting residual kidney function)

Current Best Practices

The KDIGO guidelines (global gold standard for kidney care) define ESRD at eGFR 15 (≈ creatinine 400-500) but emphasize:
❗ “ESRD diagnosis ≠ automatic dialysis indication”

Three Key Considerations Before Dialysis:

1. Complication severity: Are symptoms life-threatening or manageable medically?
2. Reversible factors: Could treatment recover some function? (e.g., infections, obstruction)
3. Medication response: How well are current therapies working?

A Cautionary Case Study: Mr. Wang from Jiangsu

History: 12-year CKD patient, started dialysis at creatinine 623 μmol/L
Outcome: After comprehensive treatment addressing reversible factors:

• Discontinued dialysis within months
• Creatinine stabilized at 70-76 μmol/L (near normal)

Lessons from This Case:

1. Don’t rush to dialysis just because creatinine is “high”
2. Assess treatable factors first
3. Preserve residual function – premature dialysis can accelerate its loss

When Dialysis Might Be Premature

Red flags suggesting unnecessary dialysis:

• Creatinine 500-600 without severe symptoms
• Stable condition on medications
• Potential reversible contributors present

Remember: The removal of the “707 rule” was meant to enable better care – not lower standards. Each case deserves thoughtful evaluation.

Key Adaptations for U.S. Audience:

1. Measurement Units: Included both μmol/L and mg/dL (standard in U.S. practice)
2. Guideline Context: Highlighted KDIGO as the authoritative source
3. Clinical Terms: Used “eGFR” alongside creatinine for familiarity
4. Case Presentation: Framed as a teachable moment rather than criticism
5. Visuals: Maintained original author image for credibility

This version preserves all medical nuances while making the content accessible to English-speaking patients and providers. Let me know if you’d like any adjustments for your specific audience.