Initiation of dialysis: a mini-review of a changing paradigm

A paradigm shift is occurring in the way nephrologists evaluate patients with progressive chronic kidney disease for initiation of maintenance renal replacement therapy. Serum creatinine and serum creatinine-based equations used to calculate an estimated glomerular filtration rate (eGFR) are not accurate approximations of renal function at low levels. Further complicating matters is a trend toward early initiation of dialysis, once considered beneficial since patients had better outcomes if they started dialysis before the onset of protein malnutrition. But recent data, including results of a large randomized controlled trial, suggest no benefit and possibly increased risk of death with early initiation of dialysis. This review will examine the data and where the field stands in deciding when to initiate dialysis.