Because of the poor dialysis situation in our country (and in similar so called developing countries) we do not usually start our patients on maintenance dialysis early. Most patients have obvious uraemic manifestations when they are started (Creatinine clearance usually 5ml/min or less). Some in fact start their dialysis as an emergency life saving procedure. In contrast most patients with chronic renal failure in developed countries start dialysis as a carefully planned procedure before they develop obvious uraemic manifestations (creatinine clearance of 10 ml/min or more). We have been told that early dialysis improves survival and quality of life.
In a recent randomized controlled trial (called Initiating Dialysis Early and Late –IDEAL) conducted at 32 centers in Australia and New Zealand and reported in the August 12 issue of the New England Journal of Medicine(1); Bruce A. Cooper from Royal North Shore Hospital and Sydney Medical School in Sydney (Australia) and Colleagues examined whether the timing of the initiation of maintenance dialysis influenced survival among patients with chronic kidney disease. Between July 2000 and November 2008, eight hundred twenty eight adults (542 men and 286 women) with progressive chronic kidney disease were randomly assigned to an early start group (creatinine clearance between 10 and 14 ml/min) and a late start group (creatinine clearance between 5 and 7 ml/min or the development of obvious uraemic manifestations). At the end of study the authors concluded that planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes. In an accompanying editorial, Norbert Lameire and Wim Van Biesen from the University Hospital Ghent in Ghent, Belgium commented : "In our view, the IDEAL trial supports the currently recommended practice, in which most nephrologists start patients on renal-replacement therapy on the basis of clinical factors rather than numerical criteria such as the estimated GFR alone,"
Our dialysis policy may after all not be as bad as we think!!??
(1) Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA, A randomized controlled trial of early versus late initiation of dialysis, N Engl J Med, 2010,363(7):609-19.