title: Delaying initiation of dialysis till symptomatic uraemia--is it too late?
abstract: BACKGROUND
  The optimal timing of initiating renal replacement therapy in patients with chronic renal failure remains uncertain. The primary objective of our study is to determine whether delaying dialysis initiation as a result of patients' choice may have any impact on survival in subjects with end-stage renal disease.
  
  
  METHODS
  We prospectively studied the clinical outcome during the first year of all consecutive patients (n=233) deemed suitable for peritoneal dialysis (PD) after pre-dialysis counselling over a 2-year period from 2002 to 2004. All patients who were offered dialysis were included in the analysis from the day of initial counselling regardless of whether or not they were eventually established on PD.
  
  
  RESULTS
  There were 151 'elective starters' (50.3% male, mean+/-SD age=57.7+/-13.9 years, 39.7% diabetic) who were electively initiated on dialysis when glomerular filtration rate reached 10 ml/min/1.73 m2 or below. The remaining 82 subjects (53.7% male, mean+/-SD age=58.4+/-11.3 years, 46.3% diabetic, P=0.33 vs elective starters) declined dialysis initially (initial refusers). On follow-up, 45 (55%) initial refusers developed a uraemic emergency and agreed to undergo dialysis, and 39 (48%) were eventually established on maintenance PD (late starters). Kaplan-Meier analysis of 1-year survival showed a significantly higher rate of all-cause (18.3% vs 6.6%, P=0.004, log-rank test) and cardiovascular (9.8% vs 2.6%, P=0.014) mortality among the initial refusers.
  
  
  CONCLUSIONS
  Patients who refuse timely start of dialysis have worse overall outcome at one year after the offer of dialysis, compared with elective starters.
authors.affiliation: Department of Medicine, The University of Hong Kong and Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China. scwtang@hku.hk
authors.forename: Sydney C W
authors.initials: SC
authors.lastname: Tang
authors.forename: Yiu Wing
authors.initials: YW
authors.lastname: Ho
authors.forename: Anthony W C
authors.initials: AW
authors.lastname: Tang
authors.forename: Yuk Yee
authors.initials: YY
authors.lastname: Cheng
authors.forename: Frances H
authors.initials: FH
authors.lastname: Chiu
authors.forename: Wai Kei
authors.initials: WK
authors.lastname: Lo
authors.forename: Kar Neng
authors.initials: KN
authors.lastname: Lai
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010530:Peritoneal Dialysis / Q000379:methods; D010531:Peritoneal Dialysis, Continuous Ambulatory; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D016312:Treatment Refusal; D014511:Uremia / Q000209:etiology*