When to initiate renal replacement therapy: The trend of dialysis initiation

Abstract

The timing of renal replacement therapy for patients with end-stage renal disease has been subject to considerable variation. The United States Renal Data System shows an ascending trend of early dialysis initiation until 2010, at which point it decreased slightly for the following 2 years. In the 1990s, nephrologists believed that early initiation of dialysis could improve patient survival. Based on the Canadian-United States Peritoneal Dialysis study, the National Kidney Foundation Dialysis Outcomes Quality Initiative recommended that dialysis should be initiated early. Since 2001, several observational studies and 1 randomized controlled trial have found no beneficial effect when patients were placed on dialysis early. In contrast, they found that an increase in mortality was associated with early dialysis initiation. The most recent dialysis initiation guidelines recommend that dialysis should be initiated at an estimated glomerular filtration rate (eGFR) of greater than or equal to 6 mL/min per 1.73 m(2). Nevertheless, the decision to start dialysis is mainly based on a predefined eGFR value, and no convincing evidence has demonstrated that patients would benefit from early dialysis initiation as indicated by the eGFR. Even today, the optimal dialysis initiation time remains unknown. The decision of when to start dialysis should be based on careful clinical evaluation.

Keywords: Creatinine clearance; Dialysis; End-stage renal disease; Estimated glomerular filtration rate; Renal replacement therapy; Survival.

Figure 1

Percentage of patients initiating renal replacement therapy “early” in the United States during the years 1996-2012. Data from the United states Renal Data system. eGFR calculated using the CKD-EPI equation [CKD-EPI eGFR (mL/min per 1.73 m²)]. ESRD: End-stage renal disease; eGFR: Estimated glomerular filtration rate.