At what GFR should renal replacement therapy be considered?

• A. <15 ml/min/1.73 m2
• B. <45 ml/min/1.73 m2
• C. <60 ml/min/1.73 m2
• D. <30 ml/min/1.73 m2

Answer: (D)

As kidney function declines, it’s reasonable to begin discussing replacement therapy when the GFR falls to about 30 ml/min/1.73 m2. At this level, the risk of uremic complications, electrolyte disturbances, and acid-base issues increases, and the clinical trajectory toward end-stage disease becomes clearer, so proactive planning helps prevent urgent dialysis. The decision to start dialysis is ultimately driven by symptoms and overall status (uremia signs, refractory hyperkalemia, metabolic acidosis, fluid overload, nutritional decline) rather than GFR alone. Many patients can defer dialysis until GFR approaches the mid-teens if they are asymptomatic, but below 30 ml/min/1.73 m2 it’s appropriate to start considering options and arranging timely initiation if symptoms develop.