title: An assessment of dialysis provider's attitudes towards timing of dialysis initiation in Canada.
abstract: BACKGROUND
  Physicians' perceptions and opinions may influence when to initiate dialysis.
  
  
  OBJECTIVE
  To examine providers' perspectives and opinions regarding the timing of dialysis initiation.
  
  
  METHODS
  Online survey.
  
  
  METHODS
  Community and academic dialysis practices in Canada.
  
  
  METHODS
  A nationally-representative sample of dialysis providers.
  
  
  METHODS
  Dialysis providers opinions assessing reasons to initiate dialysis at low or high eGFR. Responses were obtained using a 9-point Likert scale. Early dialysis was defined as initiation of dialysis in an individual with an eGFR greater than or equal to 10.5 ml/min/m(2). A detailed survey was emailed to all members of the Canadian Society of Nephrology (CSN) in February 2013. The survey was designed and pre-tested to evaluate duration and ease of administration.
  
  
  RESULTS
  One hundred and forty one (25% response rate) physicians participated in the survey. The majority were from urban, academic centres and practiced in regionally administered renal programs. Very few respondents had a formal policy regarding the timing of dialysis initiation or formally reviewed new dialysis starts (N = 4, 3.1%). The majority of respondents were either neutral or disagreed that late compared to early dialysis initiation improved outcomes (85-88%), had a negative impact on quality of life (89%), worsened AVF or PD use (84-90%), led to sicker patients (83%) or was cost effective (61%). Fifty-seven percent of respondents felt uremic symptoms occurred earlier in patients with advancing age or co-morbid illness. Half (51.8%) of the respondents felt there was an absolute eGFR at which they would initiate dialysis in an asymptomatic patient. The majority of respondents would initiate dialysis for classic indications for dialysis, such as volume overload (90.1%) and cachexia (83.7%) however a significant number chose other factors that may lead them to early dialysis initiation including avoiding an emergency (28.4%), patient preference (21.3%) and non-compliance (8.5%).
  
  
  CONCLUSIONS
  25% response rate.
  
  
  CONCLUSIONS
  Although the majority of nephrologists in Canada who responded followed evidence-based practice regarding the timing of dialysis initiation, knowledge gaps and areas of clinical uncertainty exist. The implementation and evaluation of formal policies and knowledge translation activities may limit potentially unnecessary early dialysis initiation.
authors.affiliation: Department of Medicine, University of Calgary, Calgary, Alberta Canada.
authors.forename: Bikaramjit S
authors.initials: BS
authors.lastname: Mann
authors.affiliation: Department of Medicine, University of Calgary, Calgary, Alberta Canada.
authors.forename: Braden J
authors.initials: BJ
authors.lastname: Manns
authors.affiliation: Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba Canada.
authors.forename: Allison
authors.initials: A
authors.lastname: Dart
authors.affiliation: Saskatoon Health Region, University of Saskatchewan, Saskatoon, Saskatchewan Canada.
authors.forename: Joanne
authors.initials: J
authors.lastname: Kappel
authors.affiliation: Faculty of Nursing, University of Alberta, Edmonton, Alberta Canada.
authors.forename: Anita
authors.initials: A
authors.lastname: Molzahn
authors.affiliation: Division of Nephrology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario Canada.
authors.forename: David
authors.initials: D
authors.lastname: Naimark
authors.affiliation: 7Jewish General Hospital, McGill University, Montreal, Quebec Canada.
authors.forename: Sharon J
authors.initials: SJ
authors.lastname: Nessim
authors.affiliation: Department of Medicine, Dalhousie University, Halifax, Nova Scotia Canada.
authors.forename: Steven
authors.initials: S
authors.lastname: Soroka
authors.affiliation: McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Zappitelli
authors.affiliation: The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario Canada.
authors.forename: Manish M
authors.initials: MM
authors.lastname: Sood