Elsevier

Seminars in Nephrology

Volume 37, Issue 2, March 2017, Pages 181-193
Seminars in Nephrology

Timing of Dialysis Initiation: What Has Changed Since IDEAL?☆,☆☆

https://doi.org/10.1016/j.semnephrol.2016.12.008Get rights and content

Summary

The optimal timing of initiation of maintenance dialysis in patients with end-stage renal disease currently is unknown. This transition period is one of exceptionally high vulnerability for patients; annual mortality rates in stage 5 chronic kidney disease through the first year of maintenance dialysis exceed 20%. The results of the Initiating Dialysis Early and Late (IDEAL) study, a randomized trial that tested the impact of dialysis initiation at two different levels of kidney function on outcomes, showed no significant difference in survival or other patient-centered outcomes between treatment groups. These data have challenged the established paradigm of using estimates of glomerular filtration as the primary guide for initiation of maintenance dialysis and illustrate the compelling need for research to optimize the high-risk transition period from chronic kidney disease to end-stage renal disease. This article reviews the findings of the IDEAL study and summarizes the evolution of research findings, updated clinical practice guidelines, and trends in dialysis initiation practices in the United States in the 6 years since the publication of the results from IDEAL. Complementary strategies to the use of estimated glomerular filtration rate to optimally time the initiation of maintenance dialysis and potentially improve patient-centered outcomes also are considered.

Section snippets

Study Overview and Findings

The IDEAL study was conducted between July 2000 and November 2008, and enrolled a total of 828 adults with progressive advanced CKD, defined as an eGFR (calculated by the Cockcroft-Gault equation) of 15 mL/min/1.73 m2 of body surface area. Patients were recruited at 32 centers in Australia and New Zealand and were randomized to initiate dialysis at an eGFR of 10 to 15 mL/min/1.73 m2 (termed early start) or when the eGFR had decreased to 5 to 7 mL/min/1.73 m2 (termed late start). Patients were

Timing of Dialysis Initiation and Mortality: Evidence from Studies Since Ideal

Although the IDEAL study remains the only large randomized controlled trial published to date that specifically aimed to evaluate the benefit of initiation of dialysis at a high versus low level of eGFR, research exploring various aspects of the timing of dialysis initiation has continued in the 6 years since the publication of IDEAL. A number of observational cohort studies using large data sets have sought to test modified versions of the hypothesis tested in the IDEAL study, while attempting

The Evolution of Clinical Practice Guidelines on the Timing of Dialysis Initiation

Since the publication of IDEAL, and explicitly influenced by both the IDEAL results and the growing body of observational data suggesting no benefit to early initiation of dialysis, clinical practice guidelines providing recommendations to clinicians on dialysis initiation decision making have evolved considerably (Table 1). Even before 2010, the previous version of the NKF-KDOQI clinical practice guideline for dialysis initiation published in 2006 avoided mention of a specific level of kidney

Trends in the Timing of Dialysis Initiation Since Ideal

From the mid-1990s through 2009, the mean eGFR in patients starting maintenance dialysis in the United States saw an inexorable yearly increase from 7.7 mL/min/1.73 m2 in 1996 to 11.2 mL/min/1.73 m2 in 2009.1 This irrefutable trend has been well described and discussed, and although definitive evidence of the etiology of this trend is lacking, some commentators have hypothesized that this finding may have been owing to tacit acceptance of “conventional wisdoms”20 regarding the benefit of

Non-eGFR-Based Approaches to Determine Timing of Dialysis Initiation

The results of the IDEAL study and the publication of clinical practice guidelines in the United States and abroad that have advocated a personalized approach to dialysis initiation decision making have been interpreted by many nephrologists as an endorsement that the determination of the optimal timing of dialysis initiation remains in the domain of the art, rather than the science, of medicine. There are, however, promising new areas of active inquiry in nephrology and health services

Conclusions

How should we integrate the landmark results from the IDEAL study with the subsequent research findings and clinical practice guidelines that have followed, along with the substantial number of unanswered questions regarding the optimal timing for dialysis initiation that still remain? First, it is clear that using eGFR as the primary guide for when to start dialysis in a patient with progressive advanced CKD is a strategy that likely should be abandoned. Second, dialysis initiation decision

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    Financial disclosure: Supported in part by National Institutes of Health/National Center for Advancing Translational Sciences grant KL2 TR000421 to the University of Washington Institute for Translational Health Sciences.

    ☆☆

    Conflict of interest statement: Some data in this article have been supplied by the United States Renal Data System. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the US government.

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