Pollock Carol A, Cooper Bruce A, Harris David C
Nephrol Dial Transplant. 2012 Jun;27(6):2162-6. doi: 10.1093/ndt/gfs125.
Over the last 15-20 years, there has been an increasing trend for dialysis to be commenced earlier in the development of chronic kidney disease (CKD). The drivers for initiation of dialysis at higher levels of renal function are complex but were primarily based on the assumption that by improving solute and water clearances with earlier dialysis, morbidity, mortality and quality of life would be improved. The Initiating Dialysis Early and Late (IDEAL) trial definitively demonstrated that elective earlier initiation of dialysis was not associated with improved clinical outcomes or quality of life. Indeed, no subset of patients was found to benefit from earlier dialysis. Observational data suggests that patients who commence dialysis with higher levels of renal function are more likely to have significant comorbidity that results in higher mortality rates compared to patients who remain clinically well and biochemically stable and are able to defer the initiation of dialysis till later in the course of CKD. However, patients who are able to defer dialysis should have appropriate access created so as to avoid the use of temporary catheters and to facilitate initiation using the preferred dialysis modality. Estimates of glomerular filtration rates in Stage 5 CKD have been poorly validated and should not be used as the key determinant influencing the commencement of dialysis. The results of the IDEAL trial have influenced guidelines internationally and provide clinicians, patients and health care providers with important information to drive clinical decision making and rational service planning.
在过去的15至20年里，慢性肾脏病（CKD）发展过程中更早开始透析的趋势日益明显。在肾功能较高水平时开始透析的驱动因素较为复杂，但主要基于这样一种假设，即通过早期透析改善溶质和水分清除率，发病率、死亡率和生活质量将会得到改善。早期与晚期开始透析（IDEAL）试验明确表明，选择性地更早开始透析与改善临床结局或生活质量并无关联。事实上，未发现有亚组患者能从早期透析中获益。观察数据表明，与那些临床状况良好、生化指标稳定且能够将透析起始推迟至CKD病程后期的患者相比，在肾功能较高水平时开始透析的患者更有可能患有严重合并症，从而导致更高的死亡率。然而，能够推迟透析的患者应建立合适的血管通路，以避免使用临时导管，并便于采用首选的透析方式开始透析。5期CKD患者肾小球滤过率的估计值尚未得到充分验证，不应将其用作影响透析开始的关键决定因素。IDEAL试验的结果已在国际上影响了相关指南，并为临床医生、患者和医疗服务提供者提供了重要信息，以推动临床决策和合理的服务规划。
