2011 Top Game Changers in Nephrology

George Bakris, MD; Jeffrey S. Berns, MD; Lynda A. Szczech, MD; Carol Peckham


November 16, 2011

In This Article

1. The Top 2011 Game Changer in Nephrology

When Is the Best Time to Start Dialysis?

A 2011 paper in the Archives of Internal Medicine by Rosansky and colleagues[13] and a follow-up commentary[14] addressed the issue of the appropriate time to start dialysis. Jeffrey Berns, in a Medscape commentary, said that this "particular study looked at United States RDS [Renal Data System] data from 1996 to 2006 in a large cohort of healthy dialysis patients. They had no substantial comorbidities other than hypertension, and the top age was 64 years. Patients who started dialysis with GFRs in the 5-10 mL/min range had substantially lower mortality than those who started dialysis at each successively higher level of GFR, including 10-15 mL/min and over 15 mL/min. This was a relatively healthy group. When the investigators looked at patients who were the most healthy -- that is, those who had normal albumin levels and hemoglobin levels and so forth -- the data were equally striking. This study is very important, very well done, observational, and retrospective. What would be useful here is a comparative-effectiveness study, because we really do need to balance not only this mortality difference that we are seeing but quality of life at the start of dialysis vs remaining off dialysis; an examination of those tradeoffs is sorely needed. We start dialysis sometimes at the earlier sign of symptoms, but maybe that is not appropriate either, and maybe the tradeoff is increasing mortality for dialytic management of relatively minor symptoms, something that probably needs to be more individualized."

Watch the complete commentary from Jeffrey Berns, MD.


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