Aim.The optimal time for initiating of chronic dialysis remains unknown. The scale for mortality risk assessment could help in decision-making concerning dialysis start timing.Methods.We randomly divided 1856 patients started dialysis in 2009–2016 into developmental and validation group (1:1) to create and validate scoring system «START» predicting mortality risk at dialysis initiation in order to fi nd unmodifi able and modifi able factors which could help in the decision-making of dialysis start. In the series of univariate regression models in the developmental set, we evaluated the mortality risk linked with available parameters: age, eGFR, serum phosphate, total calcium, hemoglobin, Charlson comorbidity index, diabetes status, urgency of start (turned to be signifi cant) and gender, serum sodium, potassium, blood pressure (without impact on survival). Similar hazard ratios were converted to score points.Results.The START score was highly predictive of death: C-statistic was 0.82 (95% CI 0.79–0.85) for the developmental dataset and 0.79 (95% CI 0.74–0.84) for validation dataset (both p < 0.001). On applying the cutoff between 7–8 points in the developmental dataset, the risk score was highly sensitive 81.1% and specifi c 67.9%; for validation dataset, the sensitivity was 78.9%, specifi city 67.9%. We confi rmed the similarity in survival prediction in the validation set to developmental set in low, medium and high START score groups. The difference in survival between three levels of START-score in validation set remained similar to that of developmental set: Wilcoxon = 8.78 (p = 0.02) vs 15.31 (p < 0.001) comparing low–medium levels and 25.18 (p < 0.001) vs 39.21 (p < 0.001) comparing medium–high levels.Conclusion.Developed START score system including modifi able factors showed good mortality prediction and could be used in dialysis start decision-making.
In recent years, many new data have been obtained regarding the tactics and strategy of dialysis therapy, which require a revision of existing clinical guidelines. This review of modern criteria for the adequacy of hemodialysis is built in accordance with the Working groups of the 2018 KDIGO Controversies Conference, which is the basis for the development of the update of future clinical guidelines of the International Society of Nephrology. It should be recognized that the intensification of a certain dialysis session has reached a limit in terms of improving meaningful outcomes. At the same time, the individual choice of dialysis modality, conditions for starting and preparing for it, optimization of the ultrafiltration rate, selection of the composition of dialysis solution, and the use of instrumental methods in correcting the water balance allow expanding the possibilities of treatment. The results of the treatment should be evaluated from a patient-oriented position. The concept of “target efficacy” for elderly and frailty patients should gradually give way to the concept of “target tolerance”, in which adequate dialysis should have minimal side effects. At the same time, more frequent, highly effective dialysis may be beneficial in a group of young patients with high metabolic needs. It is worth paying attention to the discord between assessing the significance of outcomes for patients and doctors: a mutual understanding of goals and desires will lead to an increase in compliance with treatment and satisfaction with its results. The purpose of any treatment (including dialysis) should, first of all, not be in conflict with the imperative "noli nocere!".
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