Background <p>Chronic kidney disease (CKD) is a significant global health concern, with kidney failure requiring dialysis or transplantation for survival. Data on clinical indications for dialysis initiation in resource-limited settings like Somaliland are scarce. This study aimed to identify the primary clinical indications for dialysis and their associated sociodemographic factors at Hargeisa Group Hospital. Unlike high-income settings where dialysis is often initiated based on laboratory markers found during routine monitoring, we hypothesized that indications in Somaliland would be primarily symptom-driven due to late-stage presentation and limited pre-dialysis care. Establishing this specific clinical profile is essential for tailoring local screening and intervention strategies.</p> Methods <p>A retrospective cross-sectional study (adhering to STROBE guidelines) was conducted using medical records of 123 incident patients who initiated maintenance hemodialysis from May 2022 to August 2024. Descriptive statistics, along with Chi-square and logistic regression analyses, were used to assess the magnitude of indications and associated factors.</p> Results <p>Uremic syndromes, particularly uremic gastritis (<i>n</i> = 54, 43.9%) and uremic encephalopathy (<i>n</i> = 36, 29.3%), were the most prevalent primary reasons for dialysis initiation. Maroodijeex accounted for the overwhelming majority of cases (92.7%). Significant demographic variations were observed; males showed a higher prevalence of uremic gastritis, while females predominantly presented with uremic encephalopathy (<i>p</i> &lt; 0.05).</p> Conclusion <p>This study highlights a high burden of late-stage CKD presentation (crash starters) in Somaliland. Addressing disparities in infrastructure and promoting equitable primary healthcare access to catch kidney impairment before uremic syndromes manifest is crucial for achieving better health outcomes.</p>