Initiation of dialysis—opinions from an international survey: Report on the Dialysis Opinion Symposium at the ERA‐EDTA Congress, 18 September 2000, Nice

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Abstract
Traditionally, dialysis therapy has been initiated only when considered absolutely necessary; when the remaining renal function is so low that the uraemic syndrome is becoming insupportable or even life‐threatening. Such clinical practice can be justified from a medical, a psychological and a socio‐economic point of view. It has been believed that the longer the burden of dialysis is postponed, the better for the patient and for society. However, evidence now suggests that malnutrition in renal disease patients develops along with the progression of renal failure, since patients adapt to the lower renal function by reducing their protein intake [1]. Other studies show strong correlation between nutritional status at the start of dialysis and outcome on dialysis [2]. Thus, it has been suggested that starting dialysis at a higher renal clearance than is normally practised, before uraemia and malnutrition have taken their toll, would have a beneficial impact on well being and survival of dialysis patients [3]. An earlier start of dialysis would require significant extension of the resources for dialysis treatment. For additional funds to be allocated to dialysis there is a demand for strong medical evidence of global cost effectiveness in terms of reduced morbidity and mortality. However, no such information is yet available to support the concept of an earlier start of dialysis. On the contrary, the argument of tradition carries considerable weight.