Rosansky Steven J, Cancarini Giovanni, Clark William F, Eggers Paul, Germaine Michael, Glassock Richard, Goldfarb David S, Harris David, Hwang Shang-Jyh, Imperial Edwina Brown, Johansen Kirsten L, Kalantar-Zadeh Kamyar, Moist Louise M, Rayner Brian, Steiner Robert, Zuo Li
Dorn Research Institute, WJBDVA Hospital, University of SC School of Public Health, Columbia, South Carolina.
Semin Dial. 2013 Nov-Dec;26(6):650-7. doi: 10.1111/sdi.12134. Epub 2013 Sep 19.
The recent trend to early initiation of dialysis (at eGFR >10 ml/min/1.73 m(2) ) appears to have been based on conventional wisdoms that are not supported by evidence. Observational studies using administrative databases report worse comorbidity-adjusted dialysis survival with early dialysis initiation. Although some have concluded that the IDEAL randomized controlled trial of dialysis start provided evidence that patients become symptomatic with late dialysis start, there is no definitive support for this view. The potential harms of early start of dialysis, including the loss of residual renal function (RRF), have been well documented. The rate of RRF loss (renal function trajectory) is an important consideration for the timing of the dialysis initiation decision. Patients with low glomerular filtration rate (GFR) may have sufficient RRF to be maintained off dialysis for years. Delay of dialysis start until a working arterio-venous access is in place seems prudent in light of the lack of harm and possible benefit of late dialysis initiation. Prescribing frequent hemodialysis is not recommended when dialysis is initiated early. The benefits of early initiation of chronic dialysis after episodes of congestive heart failure or acute kidney injury require further study. There are no data to show that early start benefits diabetics or other patient groups. Preemptive start of dialysis in noncompliant patients may be necessary to avoid complications. The decision to initiate dialysis requires informed patient consent and a joint decision by the patient and dialysis provider. Possible talking points for obtaining informed consent are provided.
近期透析起始时间提前（估算肾小球滤过率>10 ml/min/1.73 m²时）的趋势似乎是基于缺乏证据支持的传统观念。利用管理数据库进行的观察性研究报告称，提前开始透析且经过合并症调整后的透析生存率较低。尽管有些人得出结论，认为IDEAL透析起始随机对照试验提供了证据，表明透析起始时间晚的患者会出现症状，但这一观点并未得到确凿支持。早期开始透析的潜在危害，包括残余肾功能（RRF）的丧失，已有充分记录。RRF丧失率（肾功能轨迹）是透析起始决策时机的一个重要考虑因素。肾小球滤过率（GFR）低的患者可能有足够的RRF来维持数年不进行透析。鉴于延迟透析起始没有危害且可能有益，在建立起可用的动静脉通路之前推迟透析起始似乎是谨慎的做法。在早期开始透析时，不建议安排频繁的血液透析。充血性心力衰竭或急性肾损伤发作后早期开始慢性透析的益处需要进一步研究。没有数据表明早期开始透析对糖尿病患者或其他患者群体有益。对于不依从的患者，可能需要抢先开始透析以避免并发症。开始透析的决定需要患者知情同意，并由患者和透析提供者共同做出决定。文中提供了获取知情同意时可能的谈话要点。
