New clinical practice guidelines from the Canadian Society of Nephrology recommend deferred – over early – initiation of dialysis in patients with end-stage renal disease (ESRD).

With the deferred strategy, patients with an estimated glomelular filtration rate (eGFR) of <15 mL/min per 1.73 m2 need to be closely monitored by a nephrologist. Dialysis is initiated only when uremic symptoms (fluid overload, refractory hyperkalemia or acidosis) emerge or when the eGFR drops to ≤6 mL/min per 1.73m2. [CMAJ 2014;186:112-117]

The updated recommendation was based on a review of 23 studies, including the Initiating Dialysis Early and Late (IDEAL) study, a large clinical trial which showed that early dialysis did not improve survival, quality of life, or hospital admission rates in patients with chronic kidney disease (CKD) compared with late or deferred strategy. The findings start to reverse a trend toward early initiation of dialysis.

There is a lack of compelling benefit for early initiation of dialysis in CKD, said guideline chair Professor Louise M. Moist from the Western University in London, Ontario, Canada. Veering away from the practice will avoid the burden and inconvenience of an early start, which has been associated with longer time on dialysis and greater resource use, she added.

The new guideline covers adult patients (age >18 years) with ESRD (stage 5 CKD) initiating chronic hemodialysis or peritoneal dialysis. It does not consider the timing of pre-emptive transplantation, dialysis for acute kidney injury, pediatric patients, or those electing conservative management without dialysis.

The Canadian guidance does not recommend earlier initiation of dialysis in higher-risk subgroups, such as patients with diabetes. It also dropped previous recommendations to initiate dialysis based only on a decline in nutritional status (as measured by serum albumin, lean body mass, etc). The recommendation differs from that of the National Kidney Foundation’s Kidney Disease Quality Outcomes Initiative (KDOQI), which calls for nephrologists to evaluate the benefits, risks and disadvantages of beginning kidney replacement therapy at eGFR <15 mL/min and the Caring for Australians with Renal Impairment (CARI) guidelines which recommend initiation of dialysis at eGFR <10 mL/min or if uremic symptoms or signs of malnutrition occur.

The guideline is intended not only for nephrologists but for primary care physicians, other internal medicine subspecialties, and nursing specialists caring for, referring, or co-managing treatment for patients with CKD.