title: Timing of dialysis initiation and survival in ESRD.
abstract: OBJECTIVE
  The optimal time of dialysis initiation is unclear. The goal of this analysis was to compare survival outcomes in patients with early and late start dialysis as measured by kidney function at dialysis initiation.
  
  
  METHODS
  We performed a retrospective analysis of patients entering the U.S. Renal Data System database from January 1, 1995 to September 30, 2006. Patients were classified into groups by estimated GFR (eGFR) at dialysis initiation.
  
  
  RESULTS
  In this total incident population (n = 896,546), 99,231 patients had an early dialysis start (eGFR >15 ml/min per 1.73 m(2)) and 113,510 had a late start (eGFR ≤5 ml/min per 1.73 m(2)). The following variables were significantly (P < 0.001) associated with an early start: white race, male gender, greater comorbidity index, presence of diabetes, and peritoneal dialysis. Compared with the reference group with an eGFR of >5 to 10 ml/min per 1.73 m(2) at dialysis start, a Cox model adjusted for potential confounding variables showed an incremental increase in mortality associated with earlier dialysis start. The group with the earliest start had increased risk of mortality, wheras late start was associated with reduced risk of mortality. Subgroup analyses showed similar results. The limitations of the study are retrospective study design, potential unaccounted confounding, and potential selection and lead-time biases.
  
  
  CONCLUSIONS
  Late initiation of dialysis is associated with a reduced risk of mortality, arguing against aggressive early dialysis initiation based primarily on eGFR alone.
authors.affiliation: Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Seth
authors.initials: S
authors.lastname: Wright
authors.forename: Dalia
authors.initials: D
authors.lastname: Klausner
authors.forename: Bradley
authors.initials: B
authors.lastname: Baird
authors.forename: Mark E
authors.initials: ME
authors.lastname: Williams
authors.forename: Theodore
authors.initials: T
authors.lastname: Steinman
authors.forename: Hongying
authors.initials: H
authors.lastname: Tang
authors.forename: Regina
authors.initials: R
authors.lastname: Ragasa
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Goldfarb-Rumyantzev
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015982:Bias; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D016016:Proportional Hazards Models; D012042:Registries; D006435:Renal Dialysis / Q000401:mortality*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States