Time’s up! start dialysis later in children

In adults, there had been a consistent trend toward initiating dialysis later, at lower levels of kidney function (eGFR). Observational studies have had conflicting results, with more recent studies indicating that early dialysis initiation may be harmful.2,3 Only a single trial informs clinical practice: the Initiating Dialysis Early and Late (IDEAL) trial, published in 2010. This trial randomized 828 adults with progressive CKD to start dialysis at an eGFR of 10–15 or 5–7 ml/min per 1.73 m2.4 Although the separation between groups was lower than intended at 2.2 ml/min per 1.73 m2, there was a 6-month difference in the timing of dialysis initiation between the two groups. Uremic symptoms were cited as the reason for protocol violation among most patients in the late-start group. The study, which included a wide range of outcomes, concluded there was no improvement in mortality or quality of life, and that costs were higher in the early-start arm. Although potentially underpowered, and with less between-group separation than was planned, IDEAL demonstrated that starting dialysis based on eGFR alone is unlikely to benefit patients. What is indisputable is that starting dialysis “early,” means “early” exposure to the physical and psychosocial complications of dialysis. The publication of IDEAL has coincided or lead to patients starting dialysis later, with the average eGFR at initiation of dialysis among adults in the United States falling since 2010.