New Guidelines for Starting Dialysis in Chronic Kidney Disease

Dialysis treatment can be delayed in asymptomatic adults with chronic kidney disease, according to new guidelines from the Canadian Society of Nephrology.

The recommendation advocates an “intent-to-defer” dialysis over an “intent-to-start early,” using the patients estimated glomerular filtration rate (eGFR) to decide when to initiate treatment.

A nephrologist would closely monitor a patient with eGFR below 15 mL/min per 1.73 m2, and dialysis would begin at the first onset of a clinical indication or a decline in the eGFR to 6 mL/min per 1.73 m2 or less.

Clinical indications would include uremia, fluid overload, and refractory hyperkalemia or academia. Researchers based their guidelines on evidence from 23 studies, including the recent Initiating Dialysis Early and Late study, which reviewed survival rates and costs of early vs. late dialysis.

“Our recommendation places a high value on the avoidance of a burdensome and resource-intensive therapy that does not provide measurable benefit when started before the development of a clinical indication,” researchers concluded.

–Michael Potts

Nesrallah GE, Mustafa RA, Clark WF, Bass A, Barnieh L, et al.

Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ February 4, 2014 vol. 186 no. 2 doi: 10.1503/cmaj.130363