Are there situations when you recommend initiating dialysis in patients with advanced chronic kidney disease, even if their symptoms are minimal and electrolytes are well controlled with medical management?

Not many, but yes. If a patient had an AV graft placed for dialysis, and it has been longer than a month since the surgery, then using it if eGFR is less than 10 seems appropriate. Also, very low eGFR is probably an indication by itself. Usually, patients have symptoms before that occurs. One has to...

I try to leave a lot of the decision-making to my patients if there is no absolute need to initiate dialysis. There would have to be a good reason... an upcoming transplant or other surgery, minimal symptoms that still are negatively impacting QoL/ability to work or exercise, etc.