[Initiating dialysis early or late? New questions and new proposals]

The recent IDEAL (Initiating Dialysis Early and Late) study showed that uremic symptoms generally start when MDRD eGFR is >6 mL/min and that it is safe to delay dialysis until symptoms or biochemical evidence of uremia develop as long as the patient is already prepared for dialysis and there is adequate supervision. The results of the study support the existing guidelines and raise new questions to be answered in new trials. Francesco Casino proposes a new approach to dialysis initiation (the ''incremental approach'') whereby the dialysis dose is gradually increased as the GFR declines. Chiara Venturelli and Giuliano Brunori, on the basis of a relatively small clinical trial in the elderly (very close clinical supervision and very low protein diet supplemented with keto analogues) suggest that the start of dialysis may be delayed also to a stage where the GFR is less than 5 mL/min. Both these intriguing proposals should be considered as a rational basis for new studies rather than as recommendations for clinical practice.