RT Journal
A1 Johansen KL
T1 TIme to rethink the timing of dialysis initiation
JF Archives of Internal Medicine
JO Archives of Internal Medicine
YR 2011
FD March 14
VO 171
IS 5
SP 382
OP 383
DO 10.1001/archinternmed.2010.413
UL http://dx.doi.org/10.1001/archinternmed.2010.413
AB 
This marked change in practice was driven by the belief that earlier initiation of dialysis might result in improved survival.2 We know that markers of malnutrition present at the time of dialysis initiation are strongly associated with poor survival on dialysis, and spontaneous protein intake often falls as chronic kidney disease (CKD) progresses, possibly leading to undernutrition.3 These changes may not be reversible even after dialysis is initiated. So the theory was that malnutrition should be avoided by starting dialysis earlier, at least in patients who show signs of malnutrition, including low albumin level or low protein intake.4 Another line of reasoning held that levels of kidney function at which dialysis was being started fell well below levels that would be considered adequate for continuous dialysis therapy and that it would be logical to start dialysis around the level of kidney function equivalent to adequate peritoneal (continuous) dialysis.5 Added to this inferential evidence were preliminary data from small observational studies suggesting that survival was better with earlier initiation of dialysis. These arguments were incorporated into practice guidelines, which recommended that dialysis be started when eGFR fell below 10.5 mL/min/1.73 m2 (a level considerably above typical start points prior to that time) unless patients' nutritional status and protein intake were well preserved and patients were free of uremic signs or symptoms.4