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Review
. 2017 Mar;37(2):181-193.
doi: 10.1016/j.semnephrol.2016.12.008.

Timing of Dialysis Initiation: What Has Changed Since IDEAL?

Matthew B Rivara  1 , Rajnish Mehrotra  2
Affiliations
Review

Timing of Dialysis Initiation: What Has Changed Since IDEAL?

Matthew B Rivara et al. Semin Nephrol. 2017 Mar.

Abstract

The optimal timing of initiation of maintenance dialysis in patients with end-stage renal disease currently is unknown. This transition period is one of exceptionally high vulnerability for patients; annual mortality rates in stage 5 chronic kidney disease through the first year of maintenance dialysis exceed 20%. The results of the Initiating Dialysis Early and Late (IDEAL) study, a randomized trial that tested the impact of dialysis initiation at two different levels of kidney function on outcomes, showed no significant difference in survival or other patient-centered outcomes between treatment groups. These data have challenged the established paradigm of using estimates of glomerular filtration as the primary guide for initiation of maintenance dialysis and illustrate the compelling need for research to optimize the high-risk transition period from chronic kidney disease to end-stage renal disease. This article reviews the findings of the IDEAL study and summarizes the evolution of research findings, updated clinical practice guidelines, and trends in dialysis initiation practices in the United States in the 6 years since the publication of the results from IDEAL. Complementary strategies to the use of estimated glomerular filtration rate to optimally time the initiation of maintenance dialysis and potentially improve patient-centered outcomes also are considered.

Keywords: Kidney function; clinical outcomes; epidemiology; glomerular filtration rate; hemodialysis; mortality; peritoneal dialysis.

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Conflict of interest statement

CONFLICTS OF INTEREST

The authors report no financial conflicts of interest.

Figures

Figure 1
Figure 1. Mean eGFR at Initiation of Dialysis Among Incident End-Stage Renal Disease Cases in the United States, 1996–2013
Adapted from: United States Renal Data System Annual Data Reports from 2007, 2010, 2013, and 2015.
Figure 2
Figure 2. Future Directions: A Hypothetical Integrative Patient-Centered Approach to Decision-Making Regarding Timing of Dialysis Initaition
Abbreviations: PRO, patient-reported outcome; ClinRO, clinician-reported outcome.
See this image and copyright information in PMC

References

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