Does Uremia Mean Immediate Dialysis? The Truth Revealed

Many believe that once kidney disease progresses to uremia, dialysis must begin immediately, the sooner the better. But is this true? Today, Dr. Yang Ning shares insights that might challenge your assumptions.

Can Uremia Be Delayed?

Before diving into the topic, let’s hear about Lao Jiang, a kidney patient. Though I call him Lao Jiang, he’s not old—just in his early fifties. You’d never guess he has uremia: his face glows with health, and he’s brimming with energy, looking fitter than this “worn-out” doctor.

A year ago, Lao Jiang was diagnosed with stage 5 chronic kidney disease—uremia—with a creatinine level over 500 µmol/L and an estimated glomerular filtration rate (eGFR) of about 11 ml/min/1.73m². His kidneys had shrunk. Initially, he refused to accept the diagnosis, withdrawing into silence, while his family, fearing for his mental state, stayed by his side.

At his first visit to my clinic, Lao Jiang was visibly dejected, barely speaking as his family tearfully recounted his condition. After assessing his case, I realized he needed more than treatment—he needed hope. I explained that uremia doesn’t always mean immediate dialysis. With proper management, delaying dialysis is possible.

That conversation sparked hope. Lao Jiang shifted his focus to managing his life. He attended monthly nephrology checkups, adhered strictly to medications, and adopted lifestyle changes to slow disease progression. He bought a food scale to follow a high-quality, low-protein diet, quit smoking, and exercised daily. Once winded after climbing two flights of stairs, he now walks briskly and feels stronger.

A year later, Lao Jiang’s condition hasn’t worsened—it’s even slightly improved. He continues medication without dialysis. Through education, he’s learned late-stage kidney disease isn’t as daunting as he feared. He now believes he can live well, even if dialysis becomes necessary. Fellow dialysis patients have shared that dialysis is just a different way of living—one that still allows travel and contributions to family and society.

Lao Jiang’s story may prompt questions: Can you really avoid dialysis with uremia? At what creatinine level is dialysis needed?

When Does End-Stage Kidney Disease Require Dialysis?

Medical perspectives on dialysis timing have evolved. Previously, it was thought that delaying dialysis (waiting until eGFR is lower) led to more complications and worse outcomes, favoring early dialysis. However, recent studies, like the IDEAL trial from Australia and New Zealand, challenge this. Comparing early and late dialysis, the trial found no significant differences in mortality, infections, cardiovascular issues, or dialysis complications. Delaying dialysis didn’t worsen outcomes.

In 2015, the KDOQI guidelines updated dialysis timing recommendations. Decisions shouldn’t rely solely on kidney function metrics like creatinine levels. Instead, they should consider symptoms, physical signs, and nutritional status. Uremia-related symptoms include malnutrition, persistent fluid overload, fatigue, loss of appetite, cognitive issues, and uncontrollable lab abnormalities like high potassium, acidosis, or hyperphosphatemia.

If a patient’s eGFR drops below 15 ml/min or lower but they remain symptom-free, with stable internal balance and good nutrition, medication-based management may continue without rushing to dialysis. However, this requires strict patient cooperation. While delaying dialysis is theoretically possible, poor adherence increases risks, potentially leading to emergency dialysis or life-threatening complications.

In short, deciding when to start dialysis is complex, unlike choosing to take a pill. Only through active collaboration between patients and doctors can planned dialysis become feasible, maximizing non-dialysis time and improving outcomes.