When Should Dialysis Begin
Two factors should be consirdered when dialysis is begun in End Stage Renal Disease (ESRD). On one hand, maintenance dialysis can improve the quality of life of the vast majority of patients with ESRD. On the other hand, long time of dialysis can increase treatment burden, because patients need to adjust the life pace to accommodate dialysis time. Maintenance dialysis should be initiated when the risk of uremic syndrome is greater than the burden of treatment.
The available data suggest that it is not reasonable to estimate the start time of dialysis based only on laboratory tests (estimated glomerular filtration rate [eGFR]). Because most studies have shown that starting dialysis at different GFR levels has no significant effect on patient outcomes. There is only a randomized controlled trial to assess the point of view - the IDEAL (Initiating Dialysis Early and newest) research. There were 828 patients with ESRD in this study and they were divided into early dialysis group and late dialysis group based on creatinine clearance. After 3.6 years of median follow-up, no significant difference was found in all-cause or cardiovascular mortality, hospitalization rate, quality of life or total medical cost between the two groups.
Based on this, many experts and clinical practice guidelines recommend that maintenance dialysis should be started when uremia symptoms begin to occur. These recommendations may seem reasonable, but they should be used with caution in clinical practice for the following reasons:
1. Most uremia symptoms are not very obvious and patients have no obvious abnormality or no clear evaluation criteria when fatigue, lack of energy and mild function declines. At this time, Clinicians should carefully identify patients with clinical symptoms so as to help patients get better treatment.
2. Dialysis treatment can not improve all uremia symptoms. There is no sufficient evidence to show which clinical manifestations can be improved by maintenance dialysis. The available data suggest that appetite loss and volume overload can be ameliorated within months of initiation of dialysis.
3. Some clinical symptoms have a greater impact on patient health. Longitudinal studies have shown that patients who start dialysis because of volume overload are at higher risk of death.In addition to the examination indicators and clinical symptoms, other important factors should be taken into consideration when patients start dialysis. For example, some ESRD patients are not willing to take dialysis and choose non-dialysis treatment. Therefore, the doctor must communicate with the patient regularly to clarify patients’ intention. In addition, the first dialysis treatment for most patients is urgent and unplanned, and dialysis access and dialysis mode are not the preferred clinical access and mode.
Thus, patients with no symptoms can delay dialysis to better choose dialysis mode and dialysis vascular access implantation time. However, patients with late stage of CKD and refractory uremic clinical manifestations including but not limited to volume overload or electrolyte disturbances, should not be excluded from dialysis on the basis of high GFR alone.
The optimal time to start dialysis needs further study. Treatment should be given with comprehensive assessment of the patient's clinical symptoms and individualized examine indicators.
***Please seek professional medical advise for the diagnosis or treatment of any ailment, disease or medical condition. This article is not intended to be a substitute for the advice of a licensed medical professional.***