Getting dialysis starts with a nephrologist (kidney specialist) determining that your kidneys can no longer filter waste well enough on their own. Most people begin dialysis when their kidney function drops to about 5 to 10 percent of normal, though the exact timing depends on symptoms. The process involves choosing a type of dialysis, having a minor surgical procedure to create an access point, and then beginning regular treatments either at a clinic or at home.
When Dialysis Becomes Necessary
Your kidneys are typically monitored through a blood test that estimates how well they filter waste, measured as your eGFR (estimated glomerular filtration rate). A healthy eGFR is above 90. International guidelines recommend starting dialysis when that number falls into the 5 to 10 range, which represents severe kidney failure. At that point, most people experience symptoms like persistent nausea, loss of appetite, swelling, fatigue, or difficulty concentrating because waste products are building up in the blood.
Interestingly, kidney function below 6 percent rarely causes noticeable symptoms beyond appetite loss. So the decision to start isn’t based purely on a number. Your nephrologist weighs your lab results against how you actually feel and whether your body is managing fluid and electrolyte balance. Some people start a bit earlier because symptoms are already affecting their quality of life; others safely defer treatment a bit longer under close monitoring.
The Steps From Diagnosis to Treatment
Most people are referred to a nephrologist by their primary care doctor after routine bloodwork shows declining kidney function. The nephrologist runs additional tests to determine the cause of the kidney disease, stages its severity, and builds a treatment plan. If your kidneys continue to decline despite medication and lifestyle changes, the conversation shifts to dialysis.
Your nephrologist helps you choose between the two main types of dialysis (hemodialysis or peritoneal dialysis), then refers you to either a dialysis facility or a renal nurse for home training. You may also be referred to a transplant center if you’re a candidate for a kidney transplant, which is considered alongside dialysis rather than after it. The goal is to have your access point surgically placed well before you actually need to start treatments, so your body has time to heal.
Choosing Between Hemodialysis and Peritoneal Dialysis
There are three main ways to receive dialysis: in-center hemodialysis, home hemodialysis, and peritoneal dialysis. Each filters waste from your blood, but the mechanics, schedule, and lifestyle impact differ significantly.
In-Center Hemodialysis
This is the most common form. You travel to a dialysis center three times a week, where trained staff connect you to a machine that draws your blood, filters it through an external membrane, and returns it to your body. Sessions typically last about four hours. The center schedules your days and times, and other patients are treated in the same room. It’s the most hands-off option since staff manage everything, but it requires the most travel time and offers the least flexibility.
Home Hemodialysis
This uses the same filtering machine but in your own home, with treatments five to seven times per week in shorter sessions. You and a partner (someone who lives with you or is reliably present) go through 8 to 12 weeks of training to learn the process. Your home needs a physical inspection beforehand, and you may need plumbing or electrical modifications to support the equipment. The tradeoff is more frequent treatments for greater schedule control and the comfort of being home.
Peritoneal Dialysis
Instead of a machine filtering your blood externally, peritoneal dialysis uses the lining of your abdomen as a natural filter. A cleansing fluid flows through a catheter into your abdomen, absorbs waste, and is drained out. It’s done every day, but no machine is required for the manual version (an automated version uses a small cycler, often overnight). Despite being a daily process, total time spent on treatment is often less than in-center hemodialysis once you factor in travel, waiting, and recovery.
Surgical Access: What Happens Before You Start
Dialysis requires a reliable way to move blood or fluid in and out of your body. The type of access depends on which dialysis you choose.
Access for Hemodialysis
The preferred option is an arteriovenous (AV) fistula, created by surgically connecting an artery to a vein in your arm. This causes the vein to grow larger and stronger, able to handle the high blood flow dialysis requires. The main drawback is time: a fistula needs 2 to 3 months to mature before it’s usable. That’s why nephrologists try to plan access surgery well ahead of the first treatment. If the fistula doesn’t develop properly, the surgery has to be repeated.
An AV graft is a second option, where a synthetic tube bridges an artery and vein. Grafts are ready in 2 to 3 weeks and can last several years with good care, but they carry higher risks of infection and blood clots compared to fistulas.
If you need dialysis urgently and don’t have a fistula or graft ready, a venous catheter is placed into a large vein in your neck or chest. Catheters work immediately, which makes them essential for emergency starts, but they’re the most prone to infection and clotting. They’re meant as a bridge while a longer-term access matures.
Access for Peritoneal Dialysis
A soft, flexible catheter is surgically placed into your abdomen. After placement, a sterile bandage covers the exit site to prevent movement and keep the area clean. The skin around the catheter needs to stay dry for 10 to 14 days, and the exit site takes 4 to 6 weeks to fully heal. Ideally, you won’t start peritoneal dialysis until healing is complete, which is another reason early planning matters.
What the First Session Feels Like
Your first hemodialysis session can feel unusual. The most common side effect is a drop in blood pressure, which may cause shortness of breath, nausea, or vomiting. Muscle cramps are also common, particularly in the legs and abdomen, often triggered by the rapid removal of excess fluid from your body. These side effects tend to be worse if you’ve gained a lot of fluid between sessions.
If you’re uncomfortable, the care team can adjust the speed of filtration, change the fluid composition, or modify your medications during the session. Over time, most people learn how much fluid and salt to consume between sessions to minimize these effects. The first few treatments are often shorter or gentler while your body adjusts.
Peritoneal dialysis tends to produce fewer dramatic side effects per session since it runs more continuously, but some people feel bloating or fullness in the abdomen while the fluid sits inside.
How Insurance Covers Dialysis
Dialysis is expensive, but Medicare provides a unique safety net. Regardless of your age, you qualify for Medicare if you have permanent kidney failure requiring regular dialysis, as long as you (or your spouse or parent) have worked long enough to be eligible for Social Security benefits.
There is a waiting period. If you qualify for Medicare solely because of kidney failure, coverage typically doesn’t start until your fourth month of dialysis. During those first three months, your employer or union health plan (or other existing coverage) pays. However, you can skip the waiting period entirely if you enroll in a Medicare-certified home dialysis training program during those first three months and your doctor expects you to complete training and dialyze at home.
If you already have Medicare through age or disability, your dialysis coverage begins without a waiting period. For those with both Medicare and private insurance through an employer, the private plan usually pays first for the initial 30 months, after which Medicare becomes the primary payer. Understanding this coordination matters because it affects your out-of-pocket costs during the transition.