Zoccali Carmine
Epidemiologia Clinica e Fisiopatologia delle Malattie Renali e Ipertensione Arteriosa, Reggio Calabria, Italy.
G Ital Nefrol. 2010 Nov-Dec;27(6):584-7.
The recent IDEAL (Initiating Dialysis Early and Late) study showed that uremic symptoms generally start when MDRD eGFR is >6 mL/min and that it is safe to delay dialysis until symptoms or biochemical evidence of uremia develop as long as the patient is already prepared for dialysis and there is adequate supervision. The results of the study support the existing guidelines and raise new questions to be answered in new trials. Francesco Casino proposes a new approach to dialysis initiation (the ''incremental approach'') whereby the dialysis dose is gradually increased as the GFR declines. Chiara Venturelli and Giuliano Brunori, on the basis of a relatively small clinical trial in the elderly (very close clinical supervision and very low protein diet supplemented with keto analogues) suggest that the start of dialysis may be delayed also to a stage where the GFR is less than 5 mL/min. Both these intriguing proposals should be considered as a rational basis for new studies rather than as recommendations for clinical practice.
近期的IDEAL（早期与晚期开始透析）研究表明，尿毒症症状通常在MDRD估算肾小球滤过率（eGFR）>6 mL/min时开始出现，并且只要患者已做好透析准备且有充分的监护，延迟透析直至出现尿毒症症状或生化证据是安全的。该研究结果支持现有指南，并提出了有待新试验解答的新问题。弗朗切斯科·卡西诺提出了一种新的开始透析的方法（“递增法”），即随着肾小球滤过率（GFR）下降，逐渐增加透析剂量。基娅拉·文图雷利和朱利亚诺·布鲁诺里基于一项针对老年人的相对小型临床试验（非常密切的临床监护以及补充酮类似物的极低蛋白饮食）提出，透析开始时间也可延迟至GFR低于5 mL/min的阶段。这两个有趣的提议都应被视为新研究的合理基础，而非临床实践的建议。
