Blog entry by Meguid El Nahas
A number of articles including that by Cooper et al (IDEAL study) explored the notion that late initiation of RRT is not harmful and may be even beneficial (Rosansky et al, 2010). It strikes me that most of these papers advocating late onset RRT and the potential harm of early RRT initiation use the wrong parameter; namely MDRD derived eGFR, a test known to be unreliable at this late stage of CKD and GFR<15. Further, eGFR in these patients would be strongly influenced by changes in serum creatinine which in turn would be affected by changes in muscle mass. So a patient with eGFR of 15ml/min may have a lower serum creatinine than one with a eGFR of 5-10ml/min as a result of muscle wasting and malnutrition and would clearly fare worse on RRT! It is high time that nephrologists stop equating GFR derived from serum creatinine based equations in advanced stages of CKD.
It is also high time that more emphasis is put on early referral for RRT rather than the actual timing of initiation of RRT; considering that in the majority of emerging countries where mortality of RRT is very high, most patients are referred to Nephrologists within 60-90 days from theinitiation of RRT! Thus depriving them from adequate pre-dialysis care and monitoring!
Read: Early Start of Dialysis: A critical Review in CJASN May 2011.