Clinical experience: how much earlier should patients really start renal replacement therapy?

Data are needed to better determine the effect of initiation of dialysis on outcome. At present, it is unknown whether any of the previously reported improvements in survival "on" dialysis in patients who start "early" is solely due to lead time bias. Everyone involved with the care of ESRD patients must understand the concept of timely initiation, believe in it, and become fully educated about it. Incremental dialysis will require closer follow-up and proactive intervention. Protein restriction to prevent progression and timely initiation to prevent symptomatology are not mutually exclusive as noted by the MDRD experience. It is uncertain how much earlier the average ESRD patient would need to start dialysis. However, based on the MDRD experience, timely initiation of dialysis may likely only represent starting dialysis 4 to 5 mo sooner than the current approach to initiation in patients followed by nephrologists pre-ESRD. This "timely" initiation of dialysis would hopefully improve patient outcomes and in the long run be less costly. A multicentered, prospective, randomized trial is needed to better define the answers to these questions.