Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Nephrol. Nov 6, 2015; 4(5): 521-527
Published online Nov 6, 2015. doi: 10.5527/wjn.v4.i5.521
When to initiate renal replacement therapy: The trend of dialysis initiation
Ze-Hua Lin, Li Zuo
Ze-Hua Lin, Li Zuo, Department of Nephrology, Beijing 100044, China
Author contributions: Lin ZH performed the majority of the writing, prepared the figures and tables; Zuo L designed the outline and coordinated the writing of the paper.
Supported by 201502010 from the Public welfare project of National Health and Family Planning Commission of the People's Republic of China.
Conflict-of-interest statement: There is no conflict of interest associated with any of the senior author or other coauthors contributed their efforts in this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Li Zuo, MD, PhD, Professor of Internal Medicine Director, Department of Nephrology, Unit 10C in Ward Building, 11 Xizhimennan Street, Xicheng District, Beijing 100044, China.
Telephone: +86-10-88324008 Fax: +86-10-66181900
Received: May 22, 2015
Peer-review started: May 25, 2015
First decision: August 4, 2015
Revised: August 17, 2015
Accepted: September 25, 2015
Article in press: September 28, 2015
Published online: November 6, 2015

The timing of renal replacement therapy for patients with end-stage renal disease has been subject to considerable variation. The United States Renal Data System shows an ascending trend of early dialysis initiation until 2010, at which point it decreased slightly for the following 2 years. In the 1990s, nephrologists believed that early initiation of dialysis could improve patient survival. Based on the Canadian-United States Peritoneal Dialysis study, the National Kidney Foundation Dialysis Outcomes Quality Initiative recommended that dialysis should be initiated early. Since 2001, several observational studies and 1 randomized controlled trial have found no beneficial effect when patients were placed on dialysis early. In contrast, they found that an increase in mortality was associated with early dialysis initiation. The most recent dialysis initiation guidelines recommend that dialysis should be initiated at an estimated glomerular filtration rate (eGFR) of greater than or equal to 6 mL/min per 1.73 m2. Nevertheless, the decision to start dialysis is mainly based on a predefined eGFR value, and no convincing evidence has demonstrated that patients would benefit from early dialysis initiation as indicated by the eGFR. Even today, the optimal dialysis initiation time remains unknown. The decision of when to start dialysis should be based on careful clinical evaluation.

Keywords: End-stage renal disease, Renal replacement therapy, Dialysis, Estimated glomerular filtration rate, Creatinine clearance, Survival

Core tip: In the United States, the number of patients who were placed on dialysis early increased dramatically from 1996 to 2010 and then decreased slightly. To investigate the proper timing of renal replacement therapy (RRT), we reviewed the literature and found that the results from different studies were conflicting, so that the optimal time of dialysis initiation remained unknown. Early initiation of RRT may contribute to the current high incidence of RRT. If properly delayed RRT initiation is demonstrated to be safe for patients, this strategy may reduce the high incidence of RRT.