Initiation of Dialysis Should be Timely: Neither Early Nor Late

Abstract

Over the last decade, individuals with end-stage renal disease (ESRD) in the United States are starting maintenance dialysis therapy at progressively higher estimated glomerular filtration rate (eGFR). Moreover, several observational studies have demonstrated an association of a higher risk of death with higher serum creatinine-based estimates of GFR at the time of initiation of dialysis. In contrast, studies in which renal function has been measured by timed urinary collection show either a lower risk of death or no significant association with higher GFR at the time of initiation of dialysis. There are numerous potential sources of bias in such observational studies, particularly in those that use serum creatinine-based eGFR. The only randomized controlled clinical trial to have examined this question did not demonstrate either benefit or harm with initiation of dialysis at higher level of renal function. Thus, the data to date suggest that eGFR should not be the sole consideration when assessing the need for initiating maintenance dialysis in patients with advanced chronic kidney disease. Given the high societal costs of starting renal replacement therapy earlier in the course of the disease, these considerations also suggest that dialysis can be safely be postponed in otherwise asymptomatic individuals with advanced chronic kidney disease. By the same token, dialysis should not be denied to individuals who could clearly benefit from renal replacement therapy simply because the GFR is too high (viz., volume overload, refractory hyperkalemia). Finally, there is a compelling need to reexamine the symptoms that could be attributed to uremia and clearly improve upon initiation of dialysis to better guide clinical decision-making.

Twice-Weekly and Incremental Hemodialysis Treatment for Initiation of Kidney Replacement Therapy

“…First, having two sessions a week means less frequent cannulations of a new ateriovenous fistula or graft, which may prolong its longevity. In addition, incremental HD may offer a compromise and reconciliation between the two camps of early vs. late dialysis initiation 32, 33 in lieu of the traditional approach of initiating thrice-weekly HD. A potential issue, however, is the report of increased mortality on Mondays and Tuesdays after longer interdialytic intervals, 34 which may reflect higher interdialytic weight gains and fluid gains 35 and hyperkalemia.…”

Timing of Dialysis Initiation and Mortality Risk in Chronic Kidney Disease: A Meta‐Analysis

“…Over the last decade, individuals with CKD in the United States have been starting dialysis therapy at a progressively higher estimated glomerular filtration rate (eGFR) . From 1996 to 2008, the percentage of patients with an eGFR above 10 mL/min per 1.73 m 2 starting dialysis rose from 25% to 54% in the United States .…”

Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

“…The idea that, in dialysis, "more is better" is not true for fragile patients. The failure of early dialysis start, which was previously considered synonymous with "healthy" dialysis start, to improve patients' prognoses, the recognition of the importance of residual kidney function in determining survival, and the association of the latter with better nutritional status are all elements in favor of a progressive, incremental dialysis start aimed at reducing dialysis-related morbidity and mitigating "dialysis shock" [21][22][23][94][95][96][97][98][99].…”