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Living FRIendly Summaries of the Body of Evidence using Epistemonikos (FRISBEE)
Medwave 2016;16(Suppl 5):e6602 doi: 10.5867/medwave.2016.6602
At which stage of end-stage kidney disease should chronic dialysis be started?
Gonzalo A Bravo-Soto, Trinidad Madrid
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Abstract

The number of patients requiring renal replacement therapy has increased exponentially in recent years. However, there is still controversy regarding the best moment to initiate chronic dialysis. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified five systematic reviews comprising 21 trials addressing the question of this article. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded delaying the initiation of dialysis probably does not increase mortality risk in chronic kidney disease and makes little or no difference in the risk of requiring a temporary catheter or having to check the vascular access.


 
Problem

Since the onset of renal replacement therapy, both peritoneal dialysis and hemodialysis have experienced an exponential growth.

Traditionally, early initiation of dialysis has been proposed in order to avoid patient's general condition deterioration, especially nutritional status. However, dialysis carries a high-cost, and leads to complications and risks, so there are also arguments for delaying its initiation.

Methods

We used Epistemonikos database, which is maintained by screening more than 30 databases, to identify systematic reviews and their included primary studies. With this information, we generated a structured summary using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies, a summary of findings table following the GRADE approach and a table of other considerations for decision-making.

Key messages

  • Delaying initiation of dialysis probably does not increase mortality in chronic kidney disease.
  • The timing of initiation of dialysis makes little or no difference in the risk of requiring a temporary catheter or having to check the vascular access.
  • Costs that could be reduced by delaying the moment of initiation of dialysis are large, but the feasibility of this measure may vary in different health systems.
About the body of evidence for this question

What is the evidence.
See evidence matrix  in Epistemonikos later

We found five systematic reviews [1],[2],[3],[4],[5] including 21 studies reported in 23 references [6],[7],[8], [9],[10],[11],[12],[13], [14],[15],[16],[17],[18],[19],[20], [21],[22],[23],[24],[25],[26],[27],[28]. Of these, only one study corresponds to a randomized controlled trial, reported in three references [10],[11],[14]. This table and the summary in general are based on the latter because observational studies did not increase the certainty of the evidence, or provide additional relevant information.

What types of patients were included

The characteristics of participants enrolled in the randomized trial [10] are:

  • The average age was 60 years, and 66% were men.
  • The percentage of diabetics was 43%.
  • The trial did not make differences based on initial dialysis mode (hemodialysis or peritoneal dialysis).

What types of interventions were included

The randomized trial [10] defined early dialysis as GFR 10-14 ml/min and late dialysis as GFR 5-7 ml/min.

What types of outcomes
were measured

The outcomes were pooled by the different systematic reviews as follows:

  • Total mortality.
  • Mortality per 1 mL/min decrease in GFR (not reported in the randomized trial).
  • Hospitalizations (not reported in the trial).
  • Temporary catheterization.
  • Need to check access.
Summary of findings

The information about the timing of initiation of dialysis is based on one randomized trial [10] including 828 patients. The inclusion of observational studies did not increase the certainty of the evidence.

The summary of findings is the following:

  • Delaying initiation of dialysis probably does not increase mortality in chronic kidney disease. The certainty of the evidence is moderate.
  • The timing of initiation of dialysis makes little or no difference in the risk of requiring a temporary catheter. The certainty of the evidence is high.
  • Early initiation of dialysis makes little or no difference in the risk of having to check the vascular access. The certainty of the evidence is high.

Other considerations for decision-making

To whom this evidence does and does not apply
  • The evidence presented in this summary applies to all patients with chronic kidney disease who are contemplating the initiation of dialysis as chronic renal replacement therapy. This evidence does not apply to patients with acute dialysis requirement or symptomatic disease.
  • This summary does not make a comparison between hemodialysis and peritoneal dialysis.
About the outcomes included in this summary
  • We selected mortality, need for temporary catheterization and need for revision of access for the summary of findings table because they are critical outcomes for decision-making about time of initiation of dialysis. This selection is based on the opinion of the authors of the summary, but coincides with the outcomes mentioned by most systematic reviews.
Balance between benefits and risks, and certainty of the evidence
  • Delaying initiation of dialysis probably does not carry an important risk for patients. Considering dialysis involves a substantial burden for patients, and often deterioration in their quality of life, the benefit/risk is probably favorable to late initiation of dialysis.
What would patients and their doctors think about this intervention
  • Most patients and their doctors should prefer late dialysis initiation considering the evidence presented in this summary.
  • However, some clinicians may still prefer early dialysis because it is the predominant dialysis mode, and it is still recommended in most guidelines. Feasibility considerations may also influence the decision.
Resource considerations
  • Costs associated to dialysis as renal replacement therapy worldwide are high. Late initiation could potentially lead to large savings to the health system
Feasibility and implementation
  • Delaying the initiation of dialysis requires a health system able to monitor patients closely and respond quickly to any emergency. This might be the main limitation in many health systems, and in its absence, it is possible that risks of late dialysis are higher than those observed in the trial.
Differences between this summary and other sources
  • The findings of this summary are consistent with the systematic reviews identified, although some give more weight to the observational studies. Some of them show differences in mortality, but when adjusted for confounding factors, the effect on mortality is similar to what was observed in the trial.
  • The findings of this summary partially agree with the main guidelines, as KDIGO guideline [29], the guideline of the National Kidney Foundation (KDOQI) [30] and the guideline of the Canadian Society of Nephrology [31]. They mention three circumstances for the initiation of dialysis: symptoms attributable to chronic kidney disease, failure to regulate blood pressure or volume overload, and clinical malnutrition. It is mentioned this occurs close to a glomerular filtration rate of 15 ml/min, but they do not recommend initiation of dialysis at a given numerical value.
  • Additionally, the three guidelines recognize the general tendency to favor early dialysis without a clear evidence base, but rather based on historical reasons related to starting dialysis in better general conditions. Only KDIGO [29] guideline cites the trial [10] included in this summary.
Could this evidence change in the future?
  • The probability that future evidence changes the conclusions of this summary is low due to the certainty of the evidence.
  • We did not identify ongoing studies in the International Clinical Trials Registry Platform of the World Health Organization or published studies not included in the systematic reviews identified.

How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.


Follow the link to access the interactive version: Early versus late initiation of dialysis in end-stage renal failure

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier. After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears.

The details about the methods used to produce these summaries are described here http://dx.doi.org/10.5867/medwave.2014.06.5997.

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

These summaries follow a rigorous process of internal peer review.

Conflicts of interest
The authors do not have relevant interests to declare.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

El número de pacientes que requiere terapia de reemplazo renal ha aumentado de forma exponencial en los últimos años. No obstante, aún persiste controversia sobre cuándo es el mejor momento para iniciar la diálisis como terapia crónica. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, identificamos cinco revisiones sistemáticas que en conjunto incluyen 21 estudios, de los cuáles sólo uno corresponde a un estudio aleatorizado. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que retrasar el inicio de diálisis probablemente no incrementa la mortalidad en insuficiencia renal crónica terminal y hace poca o ninguna diferencia en el riesgo de requerir un catéter temporal o de tener que revisar el acceso vascular.

Authors: Gonzalo A Bravo-Soto[1,2], Trinidad Madrid[2,3]

Affiliation:
[1] Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[2] Proyecto Epistemonikos, Santiago, Chile
[3] Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile

E-mail: madrid.trini@gmail.com

Author address:
[1] Facultad de Medicina
Pontificia Universidad Católica de Chile
Lira 63
Santiago Centro
Chile

Citation: Bravo-Soto GA, Madrid M. At which stage of end-stage kidney disease should chronic dialysis be started?. Medwave 2016;16(Suppl 5):e6602 doi: 10.5867/medwave.2016.6602

Publication date: 15/11/2016

PubMed record

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  1. Cantero-Muñoz P, Ruano-Ravina A, Otero-González A, Sánchez-Guisande D, González Rodríguez L. Influence of early dialysis among patients with advanced chronic renal disease: results of a systematic review. Nephrol Dial Transplant. 2010 Aug;25(8):2414-21 | CrossRef | PubMed |
  2. Nacak H, Bolignano D, Van Diepen M, Dekker F, Van Biesen W. Timing of start of dialysis in diabetes mellitus patients: a systematic literature review. Nephrol Dial Transplant. 2016 Feb;31(2):306-16 | CrossRef | PubMed |
  3. Pan Y, Xu XD, Guo LL, Cai LL, Jin HM. Association of early versus late initiation of dialysis with mortality: systematic review and meta-analysis. Nephron Clin Pract. 2012;120(3):c121-31 | CrossRef | PubMed |
  4. Slinin Y, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, et al. Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline. Am J Kidney Dis. 2015 Nov;66(5):823-36 | CrossRef | PubMed |
  5. Susantitaphong P, Altamimi S, Ashkar M, Balk EM, Stel VS, Wright S, Jaber BL. GFR at initiation of dialysis and mortality in CKD: a meta-analysis. Am J Kidney Dis. 2012 Jun;59(6):829-40 | CrossRef | PubMed |
  6. Arora P, Obrador GT, Ruthazer R, Kausz AT, Meyer KB, Jenuleson CS, et al. Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol. 1999 Jun;10(6):1281-6 | PubMed |
  7. Beddhu S, Samore MH, Roberts MS, Stoddard GJ, Ramkumar N, Pappas LM, et al. Impact of timing of initiation of dialysis on mortality. J Am Soc Nephrol. 2003 Sep;14(9):2305-12 | PubMed |
  8. Clark WF, Na Y, Rosansky SJ, Sontrop JM, Macnab JJ, Glassock RJ, et al. Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ. 2011 Jan 11;183(1):47-53 | CrossRef | PubMed |
  9. Cooper BA, Aslani A, Ryan M, Ibels LS, Pollock CA. Nutritional state correlates with renal function at the start of dialysis. Perit Dial Int. 2003 May-Jun;23(3):291-5 | PubMed |
  10. Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Dempster J, et al. IDEAL Study Steering Committee. The Initiating Dialysis Early and Late (IDEAL) study: study rationale and design. Perit Dial Int. 2004 Mar-Apr;24(2):176-81 | PubMed |
  11. Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, et al. IDEAL Study. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19 | CrossRef | PubMed |
  12. Coronel F, Cigarran S, Herrero JA. Early initiation of peritoneal dialysis in diabetic patients. Scand J Urol Nephrol. 2009;43(2):148-53 | CrossRef | PubMed |
  13. Evans M, Tettamanti G, Nyrén O, Bellocco R, Fored CM, Elinder CG. No survival benefit from early-start dialysis in a population-based, inception cohort study of Swedish patients with chronic kidney disease. J Intern Med. 2011 Mar;269(3):289-98 | CrossRef | PubMed |
  14. Harris A, Cooper BA, Li JJ, Bulfone L, Branley P, Collins JF, et al. Cost-effectiveness of initiating dialysis early: a randomized controlled trial. Am J Kidney Dis. 2011 May;57(5):707-15 | CrossRef | PubMed |
  15. Hwang SJ, Yang WC, Lin MY, Mau LW, Chen HC; Taiwan Society of Nephrology. Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan. Nephrol Dial Transplant. 2010 Aug;25(8):2616-24 | CrossRef | PubMed |
  16. Jain AK, Sontrop JM, Perl J, Blake PG, Clark WF, Moist LM. Timing of peritoneal dialysis initiation and mortality: analysis of the Canadian Organ Replacement Registry. Am J Kidney Dis. 2014 May;63(5):798-805 | CrossRef | PubMed |
  17. Kazmi WH, Gilbertson DT, Obrador GT, Guo H, Pereira BJ, Collins AJ, et al. Effect of comorbidity on the increased mortality associated with early initiation of dialysis. Am J Kidney Dis. 2005 Nov;46(5):887-96 | PubMed |
  18. Kim SG, Kim NH. The effect of residual renal function at the initiation of dialysis on patient survival. Korean J Intern Med. 2009 Mar;24(1):55-62 | CrossRef | PubMed |
  19. Korevaar JC, Jansen MA, Dekker FW, Jager KJ, Boeschoten EW, Krediet RT, et al. Netherlands Cooperative Study on the Adequacy of Dialysis Study Group. When to initiate dialysis: effect of proposed US guidelines on survival. Lancet. 2001 Sep 29;358(9287):1046-50 | PubMed |
  20. Lassalle M, Labeeuw M, Frimat L, Villar E, Joyeux V, Couchoud C, et al. Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival. Kidney Int. 2010 Apr;77(8):700-7 | CrossRef | PubMed |
  21. Rosansky SJ, Eggers P, Jackson K, Glassock R, Clark WF. Early start of hemodialysis may be harmful. Arch Intern Med. 2011 Mar 14;171(5):396-403 | CrossRef | PubMed |
  22. Sawhney S, Djurdjev O, Simpson K, Macleod A, Levin A. Survival and dialysis initiation: comparing British Columbia and Scotland registries. Nephrol Dial Transplant. 2009 Oct;24(10):3186-92 | CrossRef | PubMed |
  23. Shiao CC, Huang JW, Chien KL, Chuang HF, Chen YM, Wu KD. Early initiation of dialysis and late implantation of catheters adversely affect outcomes of patients on chronic peritoneal dialysis. Perit Dial Int. 2008 Jan-Feb;28(1):73-81 | PubMed |
  24. Stel VS, Dekker FW, Ansell D, Augustijn H, Casino FG, Collart F, et al. Residual renal function at the start of dialysis and clinical outcomes. Nephrol Dial Transplant. 2009 Oct;24(10):3175-82 | CrossRef | PubMed |
  25. Tang SC, Ho YW, Tang AW, Cheng YY, Chiu FH, Lo WK, et al. Hong Kong Peritoneal Dialysis Study Group.. Delaying initiation of dialysis till symptomatic uraemia--is it too late? Nephrol Dial Transplant. 2007 Jul;22(7):1926-32 | PubMed |
  26. Traynor JP, Simpson K, Geddes CC, Deighan CJ, Fox JG. Early initiation of dialysis fails to prolong survival in patients with end-stage renal failure. J Am Soc Nephrol. 2002 Aug;13(8):2125-32 | PubMed |
  27. Wilson B, Harwood L, Locking-Cusolito H, Chen SJ, Heidenheim P, Craik D, et al. Optimal timing of initiation of chronic hemodialysis? Hemodial Int. 2007 Apr;11(2):263-9 | PubMed |
  28. Wright S, Klausner D, Baird B, Williams ME, Steinman T, Tang H, et al. Timing of dialysis initiation and survival in ESRD. Clin J Am Soc Nephrol. 2010 Oct;5(10):1828-35 | CrossRef | PubMed | PMC |
  29. Eknoyan G, Lameire N, Eckardt KU, Kasiske BL, Wheeler DC, Levin A, et al. (2013). KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int, 3, 5-14. kdigo.org [online] | Link |
  30. Kopple JD. National kidney foundation K/DOQI clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis. 2001 Jan;37(1 Suppl 2):S66-70 | PubMed |
  31. Levin A, Hemmelgarn B, Culleton B, Tobe S, McFarlane P, Ruzicka M, … for the Canadian Society of Nephrology. (2008). Guidelines for the management of chronic kidney disease. CMAJ : Canadian Medical Association Journal, 179(11), 1154–1162 | CrossRef |
Cantero-Muñoz P, Ruano-Ravina A, Otero-González A, Sánchez-Guisande D, González Rodríguez L. Influence of early dialysis among patients with advanced chronic renal disease: results of a systematic review. Nephrol Dial Transplant. 2010 Aug;25(8):2414-21 | CrossRef | PubMed |

Nacak H, Bolignano D, Van Diepen M, Dekker F, Van Biesen W. Timing of start of dialysis in diabetes mellitus patients: a systematic literature review. Nephrol Dial Transplant. 2016 Feb;31(2):306-16 | CrossRef | PubMed |

Pan Y, Xu XD, Guo LL, Cai LL, Jin HM. Association of early versus late initiation of dialysis with mortality: systematic review and meta-analysis. Nephron Clin Pract. 2012;120(3):c121-31 | CrossRef | PubMed |

Slinin Y, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, et al. Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline. Am J Kidney Dis. 2015 Nov;66(5):823-36 | CrossRef | PubMed |

Susantitaphong P, Altamimi S, Ashkar M, Balk EM, Stel VS, Wright S, Jaber BL. GFR at initiation of dialysis and mortality in CKD: a meta-analysis. Am J Kidney Dis. 2012 Jun;59(6):829-40 | CrossRef | PubMed |

Arora P, Obrador GT, Ruthazer R, Kausz AT, Meyer KB, Jenuleson CS, et al. Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol. 1999 Jun;10(6):1281-6 | PubMed |

Beddhu S, Samore MH, Roberts MS, Stoddard GJ, Ramkumar N, Pappas LM, et al. Impact of timing of initiation of dialysis on mortality. J Am Soc Nephrol. 2003 Sep;14(9):2305-12 | PubMed |

Clark WF, Na Y, Rosansky SJ, Sontrop JM, Macnab JJ, Glassock RJ, et al. Association between estimated glomerular filtration rate at initiation of dialysis and mortality. CMAJ. 2011 Jan 11;183(1):47-53 | CrossRef | PubMed |

Cooper BA, Aslani A, Ryan M, Ibels LS, Pollock CA. Nutritional state correlates with renal function at the start of dialysis. Perit Dial Int. 2003 May-Jun;23(3):291-5 | PubMed |

Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Dempster J, et al. IDEAL Study Steering Committee. The Initiating Dialysis Early and Late (IDEAL) study: study rationale and design. Perit Dial Int. 2004 Mar-Apr;24(2):176-81 | PubMed |

Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, et al. IDEAL Study. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19 | CrossRef | PubMed |

Coronel F, Cigarran S, Herrero JA. Early initiation of peritoneal dialysis in diabetic patients. Scand J Urol Nephrol. 2009;43(2):148-53 | CrossRef | PubMed |

Evans M, Tettamanti G, Nyrén O, Bellocco R, Fored CM, Elinder CG. No survival benefit from early-start dialysis in a population-based, inception cohort study of Swedish patients with chronic kidney disease. J Intern Med. 2011 Mar;269(3):289-98 | CrossRef | PubMed |

Harris A, Cooper BA, Li JJ, Bulfone L, Branley P, Collins JF, et al. Cost-effectiveness of initiating dialysis early: a randomized controlled trial. Am J Kidney Dis. 2011 May;57(5):707-15 | CrossRef | PubMed |

Hwang SJ, Yang WC, Lin MY, Mau LW, Chen HC; Taiwan Society of Nephrology. Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan. Nephrol Dial Transplant. 2010 Aug;25(8):2616-24 | CrossRef | PubMed |

Jain AK, Sontrop JM, Perl J, Blake PG, Clark WF, Moist LM. Timing of peritoneal dialysis initiation and mortality: analysis of the Canadian Organ Replacement Registry. Am J Kidney Dis. 2014 May;63(5):798-805 | CrossRef | PubMed |

Kazmi WH, Gilbertson DT, Obrador GT, Guo H, Pereira BJ, Collins AJ, et al. Effect of comorbidity on the increased mortality associated with early initiation of dialysis. Am J Kidney Dis. 2005 Nov;46(5):887-96 | PubMed |

Kim SG, Kim NH. The effect of residual renal function at the initiation of dialysis on patient survival. Korean J Intern Med. 2009 Mar;24(1):55-62 | CrossRef | PubMed |

Korevaar JC, Jansen MA, Dekker FW, Jager KJ, Boeschoten EW, Krediet RT, et al. Netherlands Cooperative Study on the Adequacy of Dialysis Study Group. When to initiate dialysis: effect of proposed US guidelines on survival. Lancet. 2001 Sep 29;358(9287):1046-50 | PubMed |

Lassalle M, Labeeuw M, Frimat L, Villar E, Joyeux V, Couchoud C, et al. Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival. Kidney Int. 2010 Apr;77(8):700-7 | CrossRef | PubMed |

Rosansky SJ, Eggers P, Jackson K, Glassock R, Clark WF. Early start of hemodialysis may be harmful. Arch Intern Med. 2011 Mar 14;171(5):396-403 | CrossRef | PubMed |

Sawhney S, Djurdjev O, Simpson K, Macleod A, Levin A. Survival and dialysis initiation: comparing British Columbia and Scotland registries. Nephrol Dial Transplant. 2009 Oct;24(10):3186-92 | CrossRef | PubMed |

Shiao CC, Huang JW, Chien KL, Chuang HF, Chen YM, Wu KD. Early initiation of dialysis and late implantation of catheters adversely affect outcomes of patients on chronic peritoneal dialysis. Perit Dial Int. 2008 Jan-Feb;28(1):73-81 | PubMed |

Stel VS, Dekker FW, Ansell D, Augustijn H, Casino FG, Collart F, et al. Residual renal function at the start of dialysis and clinical outcomes. Nephrol Dial Transplant. 2009 Oct;24(10):3175-82 | CrossRef | PubMed |

Tang SC, Ho YW, Tang AW, Cheng YY, Chiu FH, Lo WK, et al. Hong Kong Peritoneal Dialysis Study Group.. Delaying initiation of dialysis till symptomatic uraemia--is it too late? Nephrol Dial Transplant. 2007 Jul;22(7):1926-32 | PubMed |

Traynor JP, Simpson K, Geddes CC, Deighan CJ, Fox JG. Early initiation of dialysis fails to prolong survival in patients with end-stage renal failure. J Am Soc Nephrol. 2002 Aug;13(8):2125-32 | PubMed |

Wilson B, Harwood L, Locking-Cusolito H, Chen SJ, Heidenheim P, Craik D, et al. Optimal timing of initiation of chronic hemodialysis? Hemodial Int. 2007 Apr;11(2):263-9 | PubMed |

Wright S, Klausner D, Baird B, Williams ME, Steinman T, Tang H, et al. Timing of dialysis initiation and survival in ESRD. Clin J Am Soc Nephrol. 2010 Oct;5(10):1828-35 | CrossRef | PubMed | PMC |

Eknoyan G, Lameire N, Eckardt KU, Kasiske BL, Wheeler DC, Levin A, et al. (2013). KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int, 3, 5-14. kdigo.org [online] | Link |

Kopple JD. National kidney foundation K/DOQI clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis. 2001 Jan;37(1 Suppl 2):S66-70 | PubMed |

Levin A, Hemmelgarn B, Culleton B, Tobe S, McFarlane P, Ruzicka M, … for the Canadian Society of Nephrology. (2008). Guidelines for the management of chronic kidney disease. CMAJ : Canadian Medical Association Journal, 179(11), 1154–1162 | CrossRef |

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