The Author Replies

Abstract

I thank the European Renal Best Practice (ERBP) advisory board1.Van Biesen W. Dekker F. Heimburger O. et al.European Guidelines on when to start dialysis: check the facts first before commenting.Kidney Int. 2012; 81Google Scholar for responding to my editorial.2.Rosansky S.J. The European renal best practice advisory board's dialysis initiation guidelines: one size won't fit all.Kidney Int. 2011; 80: 1005-1007Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar My primary reason for writing the editorial was to keep the issue in the academic arena and to help physicians understand the complexity of the problem.2.Rosansky S.J. The European renal best practice advisory board's dialysis initiation guidelines: one size won't fit all.Kidney Int. 2011; 80: 1005-1007Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The latest ERBP guidelines focus on the IDEAL study and ‘do not include a formal literature review’, which, in my opinion, is crucial before issuing new guidelines.3.Tattersall J. Dekker F. Heimburger O. et al.When to start dialysis: updated guidelines following publication of the Initiating Dialysis Early and Late (IDEAL) study.Nephrol Dial Transplant. 2011; 26: 2082-2086Crossref PubMed Scopus (125) Google Scholar Our main area of disagreement is the conclusion from the IDEAL study that ‘the majority of patients will develop symptoms before a MDRD eGFR of 6ml/min/1.73m2’. Although uremia is given as the reason for 73% of patients who were assigned to late start but who started early, the actual reason is unknown.4.Cooper B.A. Branley P. Bulfone L. et al.A randomized, controlled trial of early versus late initiation of dialysis.N Engl J Med. 2010; 363: 609-619Crossref PubMed Scopus (654) Google Scholar The conclusion that there is ‘high-quality evidence’ that patients will have uremic symptoms at this level of estimated glomerular filtration rate (eGFR) is not supported by the study.3.Tattersall J. Dekker F. Heimburger O. et al.When to start dialysis: updated guidelines following publication of the Initiating Dialysis Early and Late (IDEAL) study.Nephrol Dial Transplant. 2011; 26: 2082-2086Crossref PubMed Scopus (125) Google Scholar The extension of this conclusion that ‘delaying dialysis until there are symptoms that would carry a risk of harm or death due to uremia’ is not addressed in IDEAL. I am aware of only one prospective study of intentional ‘late’ dialysis initiation, an eGFR of 6ml/min per 1.73m2 (ref. 5.Di Micco L. Torraca S. Pota A. et al.Setting dialysis start at 6.0ml/min/1.73m2 eGFR—a study on safety, quality of life and economic impact.Nephrol Dial Transplant. 2009; 24: 3434-3440Crossref PubMed Scopus (23) Google Scholar). In this study, Di Micco et al.5.Di Micco L. Torraca S. Pota A. et al.Setting dialysis start at 6.0ml/min/1.73m2 eGFR—a study on safety, quality of life and economic impact.Nephrol Dial Transplant. 2009; 24: 3434-3440Crossref PubMed Scopus (23) Google Scholar enrolled 30 patients at an eGFR of 15ml/min per 1.73m2. Only 7 (23%) of the 30 patients had any of nine listed reasons, one of which was ‘uremia’, to initiate dialysis before an eGFR of 6ml/min per 1.73m2. Eight patients did not start dialysis after 21.8 months, and 14 (47%) started without developing any of the listed reasons at an eGFR of 6ml/min per 1.73m2. Thus, it is unlikely that the crossovers to early start in IDEAL were actually uremic. I agree that we need studies relating criteria used to initiate dialysis and outcomes. IDEAL does not provide any real insight into this issue.