What is the optimal timing of dialysis initiation?

Abstract

Background: The optimal timing of initiating renal replacement therapy in patients with chronic renal failure remains uncertain. The primary objective of our study is to determine whether delaying dialysis initiation as a result of patients’ choice may have any impact on survival in subjects with end-stage renal disease. Methods: We prospectively studied the clinical outcome of all consecutive patients (n=233) deemed suitable for peritoneal dialysis (PD) after predialysis counseling over a 2-year period. Results: There were 151 “elective starters” (50.3% male, mean±SD age 57.7±13.9 years, 39.7% diabetic) who were electively initiated on dialysis when glomerular filtration rate, estimated by averaging urea and creatinine clearances obtained from plasma and 24-hour urine samples, reached 10 mL/min/1.73 m2 or below. The remaining 82 subjects (53.7% male, mean±SD age 58.4±11.3 yr, 46.3% diabetic, p=0.33 vs elective starters) declined dialysis initially (refusers). On follow-up, 45 (55%) initial refusers developed a uremic emergency after a median of 12 weeks, and agreed to undergo dialysis, and 39 (48%) were eventually established on maintenance PD (late starters). Kaplan–Meier analysis of 1-year survival showed a significantly higher rate of all-cause (15.9% vs 4.0%, p=0.0003, log-rank test) and cardiovascular (9.8% vs 1.3%, p=0.0008) mortality among the initial refusers. Late starters also had higher rates of peritonitis (18 vs 42 patient-months/episode, p=0.003), hospitalization (3.14±1.17 vs 2.13±1.13 episodes, p=0.05), blood transfusion (0.8±0.35 vs 0.38±0.07 episodes, p=0.033), and less favorable nutritional indices during PD. Conclusion: Delaying dialysis initiation until the onset of symptomatic uremia adversely affects survival and well-being during the first year of dialysis.