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New Canadian guidelines suggest that nephrologists can wait to start dialysis in some chronic kidney disease patients until their estimated glomerular filtration rate (eGFR) drops below the 10 to 12 mL/min now commonly used.

Based on a literature review that includes the IDEAL trial, the Canadian Society of Nephrology recommends that patients with an eGFR below 15 mL/min be closely monitored by a nephrologist, and that dialysis doesn't need to start until a patient hits 6 mL/min or has clinical worsening.

, of Western University in Ontario and chair of the guideline committee, said in a statement that there was "no detectable evidence of benefit" for an earlier start to dialysis in terms of mortality, quality of life, or hospital admissions. She added that a later start "avoids the burden and inconvenience of an early start," which has been associated with the longer time on dialysis and greater resource use.

The Canadian recommendation is based on a review of 23 studies, including , which found that early initiation did not improve survival, quality of life, or hospital admission rates compared with a "deferred" initiation strategy.

, of the University of Washington in Seattle and chair of the American Society of Nephrology's dialysis advisory group, said he agreed that there should be a floor beyond which kidney disease patients should not be allowed to go, but that it wasn't clear that 6 mL/min is the right number.

He noted that in the IDEAL trial, the average eGFR at which dialysis was started was higher than that.

"I'd like to prevent patients from falling off a cliff," Mehrotra told 番茄社区. "We'd like for them not to have irreversible damage to their health."

Mehrotra added that the decision to start dialysis should be tailored to individual patients -- an opinion shared by several experts contacted by 番茄社区.

, of Duke University and Durham VA medical centers in North Carolina, said the initiation of dialysis "needs to be individualized, not simply generalized by an eGFR value."

Sparks said clinicians in the U.S. make the decision to start dialysis when patients develop complications that are refractory to medical management, including hypertension, fluid overload, electrolyte or acid-base derangements, or symptoms of uremia.

, of in Farmington Hills, Mich., said the findings from the IDEAL trial have started to reverse a trend toward earlier initiation of dialysis.

The study "really put the brakes on this and ... convinced a lot of nephrologists to stop using a target GFR of 10 or 12 mL/min and start waiting for symptomatic uremia to initiate dialysis," Topf said in an email to 番茄社区.

He's concerned, however, that strict guidelines fail to take into account patient-specific reasons for starting dialysis.

"Often times, very young patients will be able to tolerate extremely low GFRs without apparent symptoms, but have numerous metabolic abnormalities such as high phosphorous, high parathyroid hormone, and profound anemia that could benefit from dialysis," Topf said. "It would be a shame to prevent that therapy from being available due to a one-size-fits-all guideline that prevents individualization."

Moist and colleagues noted that the new guidance contrasts with that of the National Kidney Foundation's , which calls for nephrologists to evaluate the risks and benefits of dialysis at 15 mL/min and below. They also differ from the , which also focus on symptoms-based dialysis initiation.

, senior vice president for scientific affairs at the National Kidney Foundation, said her organization is currently upgrading the KDOQI guidelines and that the group reached similar conclusions to the Canadian guidance but will not enforce a specific eGFR target. Rather, the guidance will focus on individualization of dialysis initiation.

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