We have recently seen a certain tendency to anticipate as much as possible the beginning of dialysis in patients with severe renal diseases, but is there an evidence justifying this tendency? In Australia and New Zealand a randomized trial has been performed, where 828 adults with chronic nephropathy have been assigned to dialysis according to the value of glomerular filtration, if it had decreased to 10-14 ml/min/m2 or 5-7 ml/min/m2. If the subjects randomized to the second group (late beginning) had presented symptoms justifying it, they would have been immediately sent to dialysis. During follow-up, averagely lasted 3.6 years, the overall mortality rate has been of 37% in both groups. The incidence of cardiovascular events, infections and complications of dialysis, too, have presented similar values and at the end of the trial it was seen that the values of glomerular filtrate, when dialysis was started, were different compared to what was expected, since many patients, assigned to a late beginning, in reality have started dialysis before the established time, because of the onset of alarming symptoms: filtrate values when dialysis started were 12.0 ml/min/m2 in the group of early beginning and 9.8 ml/min/m2 in the group of late beginning. In practice, the group of “delayed” beginning started dialysis with a time difference of about 6 months compared to the group of “early” beginning.
From the trial we can deduce that the level of glomerular filtrate at which dialysis can be started can be established in 5-7 ml/min/m2, since an early beginning implies no substantial benefits for nephropathic patients. The costs/benefits relation would take much advantage from this with no damage for patients.
