Controversies in Timing of Dialysis Initiation and the Role of Race and Demographics

Authors

  • Elani Streja,

    1. Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California
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  • Susanne B. Nicholas,

    1. Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
    2. Division of Nephrology, and Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
    3. Department of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California
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  • Keith C. Norris

    Corresponding author
    1. Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
    2. Department of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California
    • Address correspondence to: Keith C. Norris, M.D., Department of Medicine, Charles R. Drew University of Medicine and Science, 1731 E. 120th Street, Los Angeles, CA 90059, Tel.: 310-249-5702; Fax: 323-357-0747, or e-mail: knorris@ucla.edu.

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Abstract

Dialysis remains the predominant form of renal replacement therapy in the United States, but the optimal timing for the initiation of dialysis remains poorly defined. Not only clinical factors such as signs/symptoms of uremia, co-existing cardiovascular disease, and presence of diabetes but also key demographic characteristics including age, gender, race/ethnicity, and socioeconomics have all been considered as potential modifying factors in the decision for the timing of dialysis initiation. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of chronic kidney disease (CKD) suggests that dialysis be initiated when signs/symptoms attributable to kidney failure such as serositis, acid-base or electrolyte abnormalities, pruritus, poorly controlled volume status or blood pressure, deteriorating nutritional status despite dietary intervention, or cognitive impairment are visible or noted. These signs/symptoms typically occur when the glomerular filtration rate (GFR) is in the range of 5–10 ml/minute/1.73 m2, although they may occur at higher levels of GFR. We review recent data on the timing of dialysis initiation, their implications for managing patients with late-stage CKD, and the important role of considering key demographics in making patient-centered decisions for the timing of dialysis initiation.

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