Evidence-based clinical decision support integrating KDIGO 2022, ERA-EDTA 2023, IDEAL Trial, and KDOQI Vascular Access guidelines with pre-dialysis workup, medication safety, and differential diagnosis modules.
Step-by-step clinical pathway from CKD staging to modality selection, grounded in KDIGO 2022 and ERA-EDTA 2023. Includes IDEAL Trial evidence for timing of elective initiation.
Comprehensive investigations and interventions required before dialysis initiation. Click items to mark as completed. Adapted from KDIGO 2022 pre-dialysis care standards and ERA-EDTA 2023.
Pre-dialysis medication reconciliation with renal dose adjustment guidance. Adjusted for eGFR thresholds per BNF/Micromedex/KDIGO 2022 pharmacotherapy recommendations.
| Drug / Class | Action at eGFR | Recommendation | Evidence | Status |
|---|---|---|---|---|
| Metformin Biguanide |
eGFR <45: reduce dose eGFR <30: STOP |
Lactic acidosis risk in renal impairment. Withhold if AKI or contrast. Discontinue permanently at eGFR <30. | 1A KDIGO | STOP <30 |
| SGLT2 Inhibitors Dapagliflozin, Empagliflozin |
eGFR <25: glycaemic benefit lost; eGFR <20: STOP for glycaemia (renoprotective benefit may persist per DAPA-CKD) | Continue for CKD progression retardation down to eGFR ≥20 (DAPA-CKD trial). Discontinue before HD initiation — dehydration/DKA risk. | 1B DAPA-CKD | Reduce/Stop |
| ACE Inhibitors / ARBs Ramipril, Losartan |
Continue through CKD if tolerated. Withhold on HD days if volume-depleted. Stop if K⁺ >6.0 mEq/L unresponsive to measures. | Continue for renoprotection and proteinuria reduction. Monitor creatinine (acceptable rise <30% from baseline). Avoid in bilateral RAS. | 1A KDIGO 2022 | Monitor |
| NSAIDs / COX-2 inhibitors Ibuprofen, Celecoxib |
All eGFR levels: avoid; esp. eGFR <30 | Contraindicated in CKD G3b+. Accelerate eGFR decline, cause AKI via NSAID-mediated afferent arteriolar constriction. Substitute paracetamol. | 1A | STOP |
| Gabapentin / Pregabalin Neuropathic pain, uraemic itch |
eGFR 30–60: reduce to 50% dose eGFR <30: 25% dose Dialysis: dose post-HD session |
Renally cleared; accumulation causes somnolence, confusion. In HD: significant dialysis clearance — dose after session (100–300 mg post-HD). | 2B | Dose Reduce |
| Low Molecular Weight Heparin Enoxaparin, Dalteparin |
eGFR <30: accumulation risk — anti-Xa monitoring or switch to UFH | Use UFH (unfractionated) in eGFR <30 or active HD. If LMWH required: anti-Xa monitoring (target 0.5–1.0 IU/mL), dose reduction (enoxaparin 1 mg/kg once daily vs BD). | 1B | Caution |
| Direct Oral Anticoagulants Apixaban, Rivaroxaban, Dabigatran |
Dabigatran: STOP eGFR <30 (dialysable) Apixaban: use 2.5 mg BD if ≥2 of: Cr>1.5, age≥80, wt≤60 kg; STOP on HD Rivaroxaban: avoid eGFR <15 |
Warfarin is preferred in CKD G4–5 AF (lower stroke risk reduction with DOACs in dialysis patients per observational data). Individual risk-benefit with haematology. | 2B | Caution/Adjust |
| Statins Atorvastatin, Rosuvastatin |
Continue through all CKD stages. Do NOT initiate in HD patients (4D, AURORA trials — no benefit, possible harm). | Continue if already established in dialysis patients. Do not start de novo in prevalent HD (KDIGO Lipids 2013). Atorvastatin preferred (mainly hepatic clearance). | 1A KDIGO Lipids | Continue (pre-HD) |
| Allopurinol Uric acid reduction |
eGFR 30–60: max 200 mg/day eGFR <30: max 100 mg/day HD: dose post-dialysis |
Accumulation of active metabolite oxipurinol causes severe toxicity (bone marrow suppression, Stevens-Johnson). Monitor allopurinol level if <eGFR 30. | 2C | Dose Reduce |
| Phosphate Binders Calcium carbonate, Sevelamer, Lanthanum |
Initiate when PO₄ >4.5 mg/dL despite dietary restriction | Non-calcium binders (sevelamer, lanthanum) preferred in dialysis — avoid calcium loading. Calcium carbonate acceptable pre-dialysis if serum Ca normal. Take with meals. | 1B KDIGO MBD | Initiate if indicated |
| ESA — Erythropoiesis Stimulating Agents Darbepoetin alfa, Epoetin alfa |
Initiate when Hb <10 g/dL after iron repletion (TSAT >20%, ferritin >100) | Target Hb 10–12 g/dL. Avoid Hb >13 g/dL (CHOIR trial: increased CV events). Reduce or withhold if Hb rising >1 g/dL per 2 weeks or Hb >12. | 1A KDIGO Anaemia | Monitor closely |
| Potassium Binders Patiromer, Sodium Zirconium Cyclosilicate |
Initiate for persistent K⁺ >5.0 mEq/L to maintain RAAS therapy | Novel agents enable continuation of ACEi/ARB in hyperkalaemia-prone CKD patients. Patiromer: 8.4 g once daily with food. SZC: 10 g TDS × 48h then 5 g/day maintenance. | 1B | Initiate if K⁺ raised |
| Aminoglycosides Gentamicin, Tobramycin |
Nephrotoxic — avoid in CKD G3b+. If essential: single-dose, level-guided, with nephrology input | If unavoidable in life-threatening infection: extended-interval dosing, trough <1 mg/L. Monitor renal function daily. Dialysis patients: dose post-HD session; obtain pre-HD trough level. | 1A | Avoid / Level-guide |
Common and important differential diagnoses for acute or subacute deterioration in eGFR in a CKD patient. Probability estimates are contextual — adjust based on clinical history, urinalysis, and imaging.
Sequential decision pathway for HD vascular access — KDOQI Vascular Access 2019 guidelines with ERA-EDTA 2023 supplementary recommendations. Fistula First principle remains the gold standard.
Radiocephalic (wrist, RC-AVF) is the preferred first attempt — lowest thrombosis, best long-term patency. If unsuitable (vein <2 mm, arterial disease): brachiocephalic (BC-AVF) or transposed brachiobasilic (BB-AVF). Requires vein diameter ≥2.5 mm and radial artery diameter ≥2.0 mm on duplex mapping.
Maturation criteria (KDOQI "Rule of 6s"): Diameter ≥6 mm, depth ≤6 mm from skin, flow ≥600 mL/min at 6 weeks post-creation.
⏱ Refer ≥6 months before anticipated HD start · Maturation 6–12 weeks · Primary failure rate: 20–40%
When autologous veins are unsuitable or primary AVF has failed. ePTFE or PTFE graft — brachio-antecubital most common. Earlier cannulation possible (2–3 weeks for standard PTFE, 24–72 hours for early cannulation grafts). Higher thrombosis and infection rates vs. AVF. Surveillance programme essential (monthly flow monitoring).
⏱ Cannulation 2–6 weeks (standard) or 24–72h (Acuseal/Flixene) · Suitable for patients with poor vein anatomy
Right internal jugular vein is the preferred site. Subclavian vein must be avoided — high risk of central vein stenosis that precludes future ipsilateral AVF/AVG. Femoral CVC only for short-term bridge in emergencies with no upper limb access. TCC carries ×3 higher mortality risk than AVF (infection, thrombosis, bacteraemia — Staphylococcus aureus most common pathogen).
⚠ Non-tunnelled CVC: maximum 7 days only. Convert to TCC or functioning AVF/AVG as soon as possible.
⏱ Right IJV preferred · Subclavian CONTRAINDICATED · Lock with citrate or heparin between sessions
For patients choosing PD as modality. Tenckhoff catheter — laparoscopic placement preferred (lower malposition rates). Break-in period: 2 weeks minimum (urgent start PD possible with low-volume supine exchanges after 1–2 days in experienced centres). Patient suitability: intact peritoneum, adequate home environment, manual dexterity or trained caregiver.
Absolute PD contraindications: extensive abdominal adhesions, active abdominal infection/IBD, large abdominal hernia (repair first), no peritoneal access possible.
⏱ Insert ≥2 weeks before PD start · Allows flush and leak testing · Urgent start possible in experienced centres
| Clinical Factor | AVF | AVG | TCC | PD Catheter |
|---|---|---|---|---|
| Adequate vein (≥2.5 mm duplex) | ✓ Preferred | Alternative | Not indicated | Not applicable |
| Poor peripheral veins | Not feasible | ✓ Preferred | Bridge | Consider PD |
| Imminent HD need (<1 week) | Not ready | Early cannulation graft | ✓ Use | Urgent start PD |
| Active systemic infection | Defer | Defer | Caution | Contraindicated |
| Patient preference — home therapy | Home HD possible | Less suitable | Not suitable | ✓ Ideal |
| Diabetic + severe peripheral vascular disease | May have arterial issues | ✓ Preferred | Bridge | Consider |
| Previous failed access (ipsilateral) | Contralateral AVF | ✓ Preferred | Bridge | Consider PD |