title: Timing of start of dialysis in diabetes mellitus patients: a systematic literature review.
abstract: BACKGROUND
  Diabetes mellitus is a frequent cause of the need for renal replacement therapy (RRT). Historically, RRT was started earlier in patients with diabetes, in an attempt to prevent complications of uraemia and diabetes. We did a systematic review to find support for this earlier start of dialysis in patients with versus without diabetes.
  
  
  METHODS
  The MEDLINE, EMBASE and CENTRAL databases were searched for articles about the timing of dialysis initiation in (subgroups of) patients with diabetes and CKD Stage 5.
  
  
  RESULTS
  A total of 340 papers were screened and 11 papers were selected to be reviewed. Only three studies showed data of at least one subgroup of patients with diabetes. Two observational studies concluded that start of dialysis with a higher estimated glomerular filtration rate (eGFR) is beneficial with regard to survival, one did not find a difference and six observational studies concluded that start of dialysis with a lower eGFR is associated with better survival in patients with diabetes. The effect of timing of initiation of dialysis did not differ between patients with versus without diabetes. Lastly, one randomized controlled trial (two papers) reported that there was no difference in survival between start at higher versus lower eGFR overall and a P-value for the interaction with diabetes of P = 0.63, indicating no difference between patients with versus without diabetes with regard to the timing of start of dialysis and subsequent mortality on dialysis.
  
  
  CONCLUSIONS
  There is no difference between early (eGFR) and late (lower eGFR) start of RRT with regard to mortality in patients with versus without diabetes. RRT should thus be initiated based on the same criteria in all patients, irrespective of the presence or absence of diabetes.
authors.affiliation: Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Hakan
authors.initials: H
authors.lastname: Nacak
authors.affiliation: European Renal Best Practice (ERBP), University Hospital Ghent, Ghent, Belgium CNR-Institute of Clinical Physiology, Reggio Calabria, Italy.
authors.forename: Davide
authors.initials: D
authors.lastname: Bolignano
authors.affiliation: Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Merel
authors.initials: M
authors.lastname: Van Diepen
authors.affiliation: Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Friedo
authors.initials: F
authors.lastname: Dekker
authors.affiliation: European Renal Best Practice (ERBP), University Hospital Ghent, Ghent, Belgium Renal Division, Ghent University Hospital, Ghent, Belgium.
authors.forename: Wim
authors.initials: W
authors.lastname: Van Biesen
mesh_terms: D003928:Diabetic Nephropathies / Q000503:physiopathology / Q000628:therapy*; D005919:Glomerular Filtration Rate / Q000502:physiology*; D006801:Humans; D006435:Renal Dialysis / Q000379:methods*; D013997:Time Factors
keywords: chronic kidney disease; diabetes mellitus; start of dialysis; survival