Initiation of dialysis: when?

Initiation of dialysis depends upon several parameters including medical and non-medical reasons. Among the medical parameters measured or calculated creatinine clearance from plasma creatinine concentration seems to be the most reliable factor although clinical parameters such as gastro-intestinal disorders, cardiovascular, hematological, neurological manifestations and last but not least general status of the patient tend to play a determinant role in the decision of initiating dialysis. Dialysis is usually initiated for patients with a normalized creatinine clearance of 5 ml/min.1.73 m2 but optional dialysis could be initiated from a normalized creatinine clearance of 10 ml/min.1.73 m2, in case the capability of the patient and the physician to tolerate the burden of uremic syndrome is overcome. Rather than employing dialysis too late, it now seems advisable to initiate dialysis earlier in the course of chronic renal failure. Actually, retrospective analysis of 167 over 625 cases records from 1981 to 1985 and of 178 over 700 case records from 1986 to 1990 in the Department of Nephrology, Necker Hospîtal, plasma creatinine concentration at initiation of dialysis of the two period was 1044 +/- 17 and 981 +/- 13 mol/L respectively, corresponding to a creatinine clearance of 6 and 7 ml/min. It is clear now that management of chronic renal failure patients should be considered as a whole and initiation of dialysis is the end point of this global strategy. Definitely, optimal time for initiating dialysis should take into account various parameters, both biological and clinical as well as associated parameters such as age of the patient and involved systemic disease.