Chronic Dialysis: Now or Later?

Published - Written by Rena Xu

The optimal timing for the initiation of dialysis among patients with Stage V chronic kidney disease (CKD) has been controversial. Some observational and case-controlled studies have suggested that starting dialysis when the estimated glomerular filtration rate (eGFR) is above 10 mL/min/1.73m2 (“early-start” dialysis) may improve patient survival and reduce morbidity compared to starting at an eGFR below this level (“late-start” dialysis). To confuse matters, other observational studies have suggested the opposite – that an early start may actually be harmful.

This week, Cooper et al. report the results of the IDEAL study, a randomized, controlled trial that compared all-cause mortality and secondary outcomes among Stage V CKD patients treated with early- vs. late-start dialysis. The trial found that early initiation did not lead to improved survival or clinical outcomes.

In the study, dialysis was initiated in patients randomized to the late-start group if their eGFR was below 7 mL/min/1.73m2 or they developed uremic symptoms or unremitting fluid overload. On average, patients in the late-start group began dialysis nearly six months later than patients in the early-start group.

NEJM Deputy Editor Dr. Julie Ingelfinger stated, “This study suggests that later initiation of dialysis is feasible for many patients with Stage V CKD. For asymptomatic patients, it is possible to wait a bit—for example, until an access has fully matured.”

This report has some important implications for the initiation of chronic dialysis, particularly given the increasing number of patients receiving dialysis worldwide. With its many complications and associated morbidity and mortality, dialysis presents a considerable personal burden to patients, limiting employment, education, and activities of daily life for many. Further, dialysis is an expensive procedure, requiring substantial human and financial resources. For these reasons, there may be benefits to later initiation.

When evaluating whether to initiate dialysis, what importance do you assign to lab data (such as eGFR) relative to clinical factors (such as the presence of uremic symptoms)?

How will the results of the IDEAL study influence your treatment of patients requiring renal replacement therapy?