Journal of the American Society of Nephrology, Vol 6, 1319-1328, Copyright © 1995 by American Society of Nephrology

REVIEWS

Initiation of dialysis

RM Hakim and JM Lazarus

The decision to initiate dialysis in a patient with progressive renal disease often depends on the physician's assessment of the patient's subjective symptoms of uremia. There is an increasing need to identify objective criteria for such a decision. Recent evidence suggests that malnutrition at the initiation of dialysis is a strong predictor of subsequent increased relative risk of death on dialysis. In this context, the role of prescribed protein restriction as well as the influence of the progression of renal disease on spontaneous dietary protein intake is examined. It is proposed that the indices of malnutrition such as progressive weight loss, serum albumin levels below 4.0 g/dL, serum transferrin levels below 200 mg/dL, and spontaneous dietary protein intake (using 24-hr urinary nitrogen measurement) below 0.8 to 0.7 g/kg per day be considered as objective criteria for the initiation of dialysis. Studies that have examined the role of "early" versus "late" dialysis have consistently shown a better outcome in the patients starting dialysis early. Other studies also suggest that early referral to nephrologists results in improved morbidity and mortality as well as hospitalization costs. An adequate vascular access, as well as social and psychological preparation of the patient, is an important early step in the process.

This article has been cited by other articles:

				B. Cianciaruso, A. Pota, A. Pisani, S. Torraca, R. Annecchini, P. Lombardi, A. Capuano, P. Nazzaro, V. Bellizzi, and M. Sabbatini Metabolic effects of two low protein diets in chronic kidney disease stage 4-5--a randomized controlled trial Nephrol. Dial. Transplant., February 1, 2008; 23(2): 636 - 644. [Abstract] [Full Text] [PDF]

				C.-y. Hsu, A. S. Go, C. E. McCulloch, J. Darbinian, and C. Iribarren Exploring Secular Trends in the Likelihood of Receiving Treatment for End-Stage Renal Disease Clin. J. Am. Soc. Nephrol., January 1, 2007; 2(1): 81 - 88. [Abstract] [Full Text] [PDF]

				S. M. Chandna, E. Kulinskaya, and K. Farrington A dramatic reduction of normalized protein catabolic rate occurs late in the course of progressive renal insufficiency Nephrol. Dial. Transplant., October 1, 2005; 20(10): 2130 - 2138. [Abstract] [Full Text] [PDF]

				C.-y. Hsu, E. Vittinghoff, F. Lin, and M. G. Shlipak The Incidence of End-Stage Renal Disease Is Increasing Faster than the Prevalence of Chronic Renal Insufficiency Ann Intern Med, July 20, 2004; 141(2): 95 - 101. [Abstract] [Full Text] [PDF]

				W. E. Mitch and G. Remuzzi Diets For Patients With Chronic Kidney Disease, Still Worth Prescribing J. Am. Soc. Nephrol., January 1, 2004; 15(1): 234 - 237. [Full Text] [PDF]

				S. Beddhu, M. H. Samore, M. S. Roberts, G. J. Stoddard, N. Ramkumar, L. M. Pappas, and A. K. Cheung Impact of Timing of Initiation of Dialysis on Mortality J. Am. Soc. Nephrol., September 1, 2003; 14(9): 2305 - 2312. [Abstract] [Full Text] [PDF]

				K. S. Kinchen, J. Sadler, N. Fink, R. Brookmeyer, M. J. Klag, A. S. Levey, and N. R. Powe The Timing of Specialist Evaluation in Chronic Kidney Disease and Mortality Ann Intern Med, September 17, 2002; 137(6): 479 - 486. [Abstract] [Full Text] [PDF]

				N. Lameire, W. V. Biesen, and R. Vanholder Initiation of dialysis--is the problem solved by NECOSAD? Nephrol. Dial. Transplant., September 1, 2002; 17(9): 1550 - 1552. [Full Text] [PDF]

				W. E. Mitch Insights into the Abnormalities of Chronic Renal Disease Attributed to Malnutrition J. Am. Soc. Nephrol., January 1, 2002; 13(90001): S22 - 27. [Abstract] [Full Text] [PDF]

				J. B. Copley Resistance Training Enhances the Value of Protein Restriction in the Treatment of Chronic Kidney Disease Ann Intern Med, December 4, 2001; 135(11): 999 - 1001. [Full Text] [PDF]

				J Stoves, C N Bartlett, and C G Newstead Specialist follow up of patients before end stage renal failure and its relationship to survival on dialysis Postgrad. Med. J., September 1, 2001; 77(911): 586 - 588. [Abstract] [Full Text] [PDF]

				I. Ledebo, M. Kessler, W. van Biesen, C. Wanner, A. Wiecek, S. Prichard, A. Argiles, and E. Ritz Initiation of dialysis--opinions from an international survey: Report on the Dialysis Opinion Symposium at the ERA-EDTA Congress, 18 September 2000, Nice Nephrol. Dial. Transplant., June 1, 2001; 16(6): 1132 - 1138. [Full Text] [PDF]

				F. Caravaca, M. Arrobas, J. L. Pizarro, and E. Sanchez-Casado Uraemic symptoms, nutritional status and renal function in pre-dialysis end-stage renal failure patients Nephrol. Dial. Transplant., April 1, 2001; 16(4): 776 - 782. [Abstract] [Full Text] [PDF]

				M. A. M. JANSEN, J. C. KOREVAAR, F. W. DEKKER, K. J. JAGER, E. W. BOESCHOTEN, and R. T. KREDIET Renal Function and Nutritional Status at the Start of Chronic Dialysis Treatment J. Am. Soc. Nephrol., January 1, 2001; 12(1): 157 - 163. [Abstract] [Full Text]

				A. T. KAUSZ, G. T. OBRADOR, P. ARORA, R. RUTHAZER, A. S. LEVEY, and B. J. G. PEREIRA Late Initiation of Dialysis among Women and Ethnic Minorities in the United States J. Am. Soc. Nephrol., December 1, 2000; 11(12): 2351 - 2357. [Abstract] [Full Text]

				F. Locatelli, F. Valderrabano, N. Hoenich, J. Bommer, K. Leunissen, and V. Cambi The management of chronic renal insufficiency in the conservative phase Nephrol. Dial. Transplant., October 1, 2000; 15(10): 1529 - 1534. [Full Text] [PDF]

				M. APARICIO, P. CHAUVEAU, V. D. PRECIGOUT, J.-L. BOUCHET, C. LASSEUR, and C. COMBE Nutrition and Outcome on Renal Replacement Therapy of Patients with Chronic Renal Failure Treated by a Supplemented Very Low Protein Diet J. Am. Soc. Nephrol., April 1, 2000; 11(4): 708 - 716. [Abstract] [Full Text] [PDF]

				C. Jacobs At which stage of renal failure should dialysis be started? Nephrol. Dial. Transplant., March 1, 2000; 15(3): 305 - 307. [Full Text] [PDF]

				C. L. MEIRELES, S. R. PRICE, A. M. L. PEREIRA, J. T. A. CARVALHAES, and W. E. MITCH Nutrition and Chronic Renal Failure in Rats: What Is an OptimalDietary Protein? J. Am. Soc. Nephrol., November 1, 1999; 10(11): 2367 - 2373. [Abstract] [Full Text]

				P. ARORA, G. T. OBRADOR, R. RUTHAZER, A. T. KAUSZ, K. B. MEYER, C. S. JENULESON, and B. J. G. PEREIRA Prevalence, Predictors, and Consequences of Late Nephrology Referral at a Tertiary Care Center J. Am. Soc. Nephrol., June 1, 1999; 10(6): 1281 - 1286. [Abstract] [Full Text]

				M. WALSER and S. HILL Can Renal Replacement Be Deferred by a Supplemented Very Low Protein Diet? J. Am. Soc. Nephrol., January 1, 1999; 10(1): 110 - 116. [Abstract] [Full Text]

				R. Walker Recent advances :General management of end stage renal disease BMJ, November 29, 1997; 315(7120): 1429 - 1432. [Full Text]

Copyright © 2008 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673