title: Timing of initiation of dialysis:  time for a new direction?
abstract: OBJECTIVE
  The past 15 years have seen tremendous growth in the initiation of dialysis at higher levels of kidney function in the setting of mixed evidence and at great societal economic cost. We review recent data on the early dialysis initiation trend, the clinical and economic impact of early dialysis initiation and the future implications for the management of advanced chronic kidney disease (CKD).
  
  
  RESULTS
  The percentage of patients who initiate dialysis with an estimated glomerular filtration rate (eGFR) above 10  ml/min/1.73m(2) is now greater than 50%, including 20% who initiate with an eGFR above 15 ml/min/1.73m(2). The drivers behind these findings are probably diverse but recent literature does not seem to support a higher symptom burden among the ageing CKD population as the major cause. The Initiating Dialysis Early And Late (IDEAL) trial provides guidance on the safety of waiting for symptoms or lower levels of estimated glomerular filtration rate prior to beginning dialysis. In addition, economic analyses based on the IDEAL and US Renal Data System findings suggest that significant cost savings could be achieved by reversing the early initiation trend.
  
  
  CONCLUSIONS
  These findings should help clinicians and policy makers looking to rein in costs while maintaining the quality of CKD care.
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Palo Alto, California 94304, USA.
authors.forename: Graham
authors.initials: G
authors.lastname: Abra
authors.forename: Manjula
authors.initials: M
authors.lastname: Kurella Tamura
mesh_terms: D003362:Cost-Benefit Analysis; D019317:Evidence-Based Medicine; D005919:Glomerular Filtration Rate; D017048:Health Care Costs; D006801:Humans; D007668:Kidney / Q000503:physiopathology*; D007674:Kidney Diseases / Q000175:diagnosis / Q000191:economics / Q000503:physiopathology / Q000628:therapy*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D006435:Renal Dialysis / Q000009:adverse effects / Q000191:economics; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome