Update of dialysis initiation timing in end stage kidney disease patients: is it a resolved question? A systematic literature review

Abstract

Chronic kidney disease (CKD) is a major global public health problem [1], and there is an increasing number of end stage kidney disease (ESKD) patients start dialysis annually. The decision on optimal initiation of maintenance dialysis is a common problem faced by nephrologists. During 1980s-2000s, extensive observational studies have been attempted to investigate the optimal estimated glomerular filtration rate (eGFR) at the start of dialysis. In 2010 a randomized controlled trial named “trial Initiating Dialysis Early and Late (IDEAL)” showed that a strategy of early dialysis initiation (target eGFR: 10-14 mL/min/1.73m2) was not superior to late initiation (waiting until symptoms develop or eGFR is 5-7 mL/ min/1.73m2) [2]. Since then, clinical practice guidelines suggest that the decision of initiate maintenance dialysis should be guided primarily by clinical constellation of signs and symptoms attributable to uremic syndrome [3– 6]. However, symptoms or signs of uremia are varied and complex, mainly depends on clinical judgment; what’s more, typical uremic symptoms such as pericarditis and encephalopathy in patients without volume overload often occur at a very low GFR, these conditions are often combined with severe metabolic disorders and/or organ damages; the exact optimal timing of dialysis for ESKD patients remains unknown. Therefore, the aim of our study is to systematically review the available evidence with regard to the optimal initiation of maintenance dialysis in ESKD patients.