When should we commence dialysis? The story of a lingering problem and today's scene after the IDEAL study.

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.