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[When to start chronic dialysis: as late as possible]
Chiara Venturelli1, Giuliano Brunori
1Struttura Complessa di Nefrologia e Dialisi, Ospedale Santa Chiara, Trento, Italy. chiara.venturelli@apss.tn.it
Summary
Starting dialysis earlier, even with a higher glomerular filtration rate (GFR), does not improve survival or quality of life in end-stage renal disease patients. Careful clinical management allows for later dialysis initiation, potentially improving outcomes.
Area of Science:
- Nephrology
- Renal Medicine
- Clinical Research
Context:
- Current guidelines recommend early dialysis initiation (GFR ≥ 10 mL/min/1.73 m2) to prevent uremic complications.
- Significant variation exists in current clinical practice regarding the timing of dialysis initiation.
- The impact of early versus late dialysis initiation on patient outcomes remains debated.
Purpose:
- To evaluate the benefits and harms of early versus late initiation of dialysis in end-stage renal disease (ESRD).
- To analyze patient survival and quality of life data based on dialysis initiation timing.
- To provide evidence-based recommendations for optimizing dialysis initiation strategies.
Summary:
- Recent studies indicate no survival benefit from initiating dialysis at a higher glomerular filtration rate (GFR).
- Early dialysis initiation may be associated with increased mortality and offers no significant quality of life improvement.
- Delayed dialysis initiation (< 7.0 mL/min) with careful clinical management, especially in elderly patients on a supplemented very low protein diet, is supported.
Impact:
- Findings challenge current recommendations for early dialysis initiation.
- Suggests that individualized, carefully managed, later dialysis initiation may be a viable strategy for ESRD patients.
- Highlights the need for personalized treatment plans considering comorbidities and nutritional status.
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