Early-Start Dialysis in Diabetic Nephropathy

Abstract

Department of Medicine, Dunedin School of Medicine, University of Otago Medical School, Dunedin, New Zealand T he point at which dialysis is initiated is still largely an empirical decision that is influenced by a number of variables, many of which are not actually linked to the individual's end-stage renal failure but rather to economic and social factors (1). The traditional approach has been to initiate dialysis only when conservative therapy fails to control uremic symptoms. However, delayed initiation of dialysis is associated with excess mortality, morbidity, and cost (2-5). A more proactive approach is to consider early initiation of dialysis to avoid the onset of uremic symp toms and their consequences. No controlled studies have been published demonstrating the benefits of early dialysis, but a number of observational studies support the concept of early-start dialysis (6). In 1978, Bonomini and colleagues (2) demonstrated a superior outcome in patients who commenced dialysis before the appearance of uremic symptoms. They showed that the 5-year survival in 34 patients started on chronic dialysis at a time when their creatinine clearance was > 10 mL/min was 100%, compared to 85% in 158 patients with a creatinine clearance of < 5 mL/min at the time of initiation of dialysis. Bonomini's group subsequently extended their observations out to a 12-year follow-up with 82 patients commencing dialysis early comp ared to 308 patients commencing dialysis late. Those who commenced early had lower mortality (survival rate 77% versus 51 %), lower hospital admissions, and better rehabilitation (7). In another study (8), an 88% 10-year survival rate was seen in patients who commenced dialysis with a creatinine clearance of 10 mL/min compared to a 55% 10-year survival in patients whose creatinine clearance was < 10 mLlmin (the mean clearance being 4 mLlmin). The level of residual re nal function at the time of commencement of dialysis