Timing of dialysis initiation: when to start? Which treatment?

During the late 1990s early initiation of dialysis was introduced on a large scale and between 1996 and 2008, the percentage of patients with an estimated glomerular filtration rate (eGFR) above 10 mL/minute starting dialysis rose from 25% to 54% in the United States. However, several subsequent studies showed no survival benefit for patients commencing dialysis earlier. One possible explanation for the negative results could be that eGFR may be a flawed index; s-creatinine is lower in patients with muscle wasting or fluid overload and these vulnerable patients with high comorbidity burden often start "early", i.e., at higher eGFR. Another explanation could be that dialysis is in fact harmful; dialysis initiation with conventional thrice weekly in-center hemodialysis clearly associates with increased initial mortality risk especially when using temporary dialysis catheters. Interestingly, patients starting on peritoneal dialysis (PD) appear to have better initial outcomes. More attention should be given to finding new objective mortality-predictive markers of uremia, reducing the use of temporary hemodialysis catheters, and increasing the use of PD as initial dialysis modality. PD may not only provide better initial dialysis outcomes but may also preserve renal function and vessels for vascular access for the benefit of better long-term outcomes.