Abstract
The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m(2) ) appears to have been based on conventional wisdoms that are not supported by evidence. Observational studies using administrative databases report worse comorbidity-adjusted dialysis survival with early dialysis initiation. Although some have concluded that the IDEAL randomized controlled trial of dialysis start provided evidence that patients become symptomatic with late dialysis start, there is no definitive support for this view. The potential harms of early start of dialysis, including the loss of residual renal function (RRF), have been well documented. The rate of RRF loss (renal function trajectory) is an important consideration for the timing of the dialysis initiation decision. Patients with low glomerular filtration rate (GFR) may have sufficient RRF to be maintained off dialysis for years. Delay of dialysis start until a working arterio-venous access is in place seems prudent in light of the lack of harm and possible benefit of late dialysis initiation. Prescribing frequent hemodialysis is not recommended when dialysis is initiated early. The benefits of early initiation of chronic dialysis after episodes of congestive heart failure or acute kidney injury require further study. There are no data to show that early start benefits diabetics or other patient groups. Preemptive start of dialysis in noncompliant patients may be necessary to avoid complications. The decision to initiate dialysis requires informed patient consent and a joint decision by the patient and dialysis provider. Possible talking points for obtaining informed consent are provided.
Highlights
Morbidity, or quality of life benefit of early dialysis initiation
Levels of 5–7 ml/min/1.73 m2 8 MDRD eGFR is inaccurate and not useful in the dialysis initiation decision 9 Frequent hemodialysis or incremental dialysis initiation may overcome some of the harm associated with early dialysis initiation and should be offered to new dialysis early starts eGFR, estimated glomerular filtration rate derived from the 4-variable Modification of Diet in Renal Disease (MDRD) formula
Three new justifications have surfaced which will be examined. These include the conclusion that the IDEAL study provided evidence that all patients will have dialysis justifying “uremic” symptoms at eGFR less than 10 ml/min/1.73 m2 [4]
Summary
As early initiation of dialysis has not been shown to be beneficial, dialysis start should be individualized and be delayed until a patient has minimal renal function unless disabling symptoms of renal failure develop. There is little proof that it is dangerous to wait until low levels of GFR are reached to start dialysis. The dangers of dialysis initiation have been well documented and the Hippocratic precept of “first do no harm” should be taken to heart. Preparation for dialysis at a later start is encouraged, taking into consideration the observed RFT. Much more work is needed to define the symptoms, signs, and laboratory findings in CKD5 that will facilitate better advice on timing of dialysis initiation. The initiation of maintenance dialysis after an AKI episode and in CHF needs further study. We conclude that available evidence shows that there is often no need to rush dialysis initiation. It may well be appropriate to describe our view as “Fools rush in where angels fear to tread.”
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