The rate of progression of late-stage chronic kidney disease (CKD) is variable and can be difficult to predict, with some patients quickly progressing to the need for renal replacement therapy and others remaining stable without it for a year or more. This unpredictability is likely due to frequently complex comorbidities and variable individual success of disease-altering therapies (eg, blood pressure control, proteinuria reduction). Studies have shown similar survival outcomes among patients started on chronic dialysis early (ie, eGFR 10-14 mL/min/1.73 m2) versus late (ie, eGFR 5-7 mL/min/1.73 m2). However, waiting until dialysis is urgently required (eg, hyperkalemia, volume overload, uremic symptoms) increases the risk for serious complications (eg, arrhythmias, respiratory failure) and should be avoided.
Survival rates with hemodialysis and peritoneal dialysis are comparable (peritoneal dialysis may be associated with slightly improved survival in the first 1-2 years after initiation), and the choice is usually based on patient preference and the ability to perform daily peritoneal dialysis at home. Peritoneal dialysis catheters can be used almost immediately following placement, but in this patient with impaired manual dexterity and minimal at-home help, peritoneal dialysis is unsuitable.
The preferred access for hemodialysis is an arteriovenous fistula, which is placed by a vascular surgeon and may take up to 6 months to mature and become usable. Therefore, to allow ample time for surgical planning and fistula maturation, patients should be referred to a vascular surgeon approximately a year in advance of anticipated hemodialysis need, a time point generally indicated by a decline in eGFR to <25 mL/min/1.73 m^2.