By Beth Piraino, MD
Kidney specialists north of the border have just released a clinical practice guideline for the timing of the start of chronic dialysis (Canadian Medical Association Journal, February, 2014). After a careful review of the literature, in particular the randomized controlled trial called the IDEAL study, the group noted that early initiation of dialysis does not improve survival or quality of life. Therefore, the recommendation is to not start dialysis based on a number estimating a patient’s kidney function, but to base the decision on patient symptoms or other indications that would improve with dialysis such as feeling sick from kidney disease (also known as ‘uremia’).
The authors of this paper are careful to point out that the guideline refers only to adults with advanced chronic kidney disease who have made a decision to do dialysis, and not to those who have chosen conservative management without dialysis or to those patients receiving a kidney transplant. The authors are also very careful to indicate the importance of close monitoring by the nephrologist so that dialysis can be started in a timely fashion when the appropriate indication develops. The authors recommend that once the eGFR drops to 6 ml/min per 1.73m2 all patients should be started on dialysis regardless of whether they have symptoms or not.
As a practicing nephrologist for over 30 years who has initiated many patients on dialysis and having seen the dramatic effect this can have on a person’s life, I embrace this guideline. In the absence of good evidence to the contrary, why not wait until there is a clear indication for dialysis? A recent study (Slinin CJASN, 2014) found that more experienced nephrologists are more likely to wait until the eGFR is <10 ml/min/1.73 m2 to start dialysis.
The new Canadian clinical practice guideline differs from the Kidney Disease Outcomes Quality Initiative of 2006 that suggest that nephrologists “evaluate the benefits, risks, and disadvantages of beginning kidney replacement therapy” at an eGFR of <15 ml/min/1.73 m2. However, it must be noted that this 2006 recommendation was prior to the IDEAL study and prior to the meta-analysis of GFR at initiation of dialysis and mortality, published in American Journal of Kidney Diseases, 2012. The more recent evidence supports the Canadian Society of Nephrology’s guideline to wait until there is a clinical indication to start dialysis.
Dr. Beth Piraino is the President of the National Kidney Foundation.