When to initiate dialysis for end-stage kidney disease: evidence and challenges

The decision about when to start dialysis for end-stage kidney disease (ESKD) is complex and is influenced by many factors. ESKD-related symptoms and signs are the most common indications for dialysis initiation. Creatinine-based formulae to estimate glomerular filtration rate (GFR) are inaccurate in patients with ESKD and, thus, the decision to start dialysis should not be based solely on estimated GFR (eGFR). Early dialysis initiation (ie, at an eGFR > 10 mL/min/1.73 m2) is not associated with a morbidity and mortality benefit, as shown in the Initiating Dialysis Early and Late (IDEAL) study. This observation has been incorporated into the latest guidelines, which place greater emphasis on the assessment of patients' symptoms and signs rather than eGFR. It is suggested that in asymptomatic patients with stage 5 chronic kidney disease, dialysis may be safely delayed until the eGFR is at least as low as 5-7 mL/min/1.73 m2 if there is careful clinical follow-up and adequate patient education. The decision on when to start dialysis is even more challenging in older patients. Due to their comorbidities and frailty, dialysis initiation may be associated with worse outcomes and quality of life. Therefore, the decision to start dialysis in these patients should be carefully weighed against its risks, and conservative care should be considered in appropriate cases. To optimise the decision-making process for dialysis initiation, patients need to be referred to a nephrologist in a timely fashion to allow adequate pre-dialysis care and planning. Dialysis initiation and its timing should be a shared decision between physician, patients and family members, and should be tailored to the individual patient's needs.