**3.1 Indications for initiation of dialysis**

The appropriate time to initiate dialysis for a patient is not clearly defined. The decision to initiate dialysis in a patient with CKD involves the consideration of subjective and objective parameters by the physician and the patient. Over the past decade a trend of increasing estimated glomerular filtration rate (eGFR) at the initiation of dialysis for treatment of ESRD has been noted in the United States. In 1996, only 19% of patients began dialysis therapy with an eGFR of greater than 10 ml/min/1.73 m2 (denoted as 'early start'), but by 2005 the fraction of early start dialysis patients had risen to 45% (5). It is not known whether early start of dialysis is beneficial, harmful or neutral with respect to the outcome of dialysis treatment for ESRD (5). The timing of initiation of dialysis for ESRD is a matter of clinical judgment guided by values of residual renal function and symptoms and signs present in the patients, including those related to comorbidity. By the time the eGFR falls below 10 ml/min/1.73 m2, most patients require dialysis. However, many patients appear to function quite well until the eGFR approaches 5 ml/min/1.73 m2. As a general rule, patients with diabetes require earlier intervention (eGFR<15 ml/min/1.73 m2) than do those with other etiologies for renal failure (6). Clearly, dialysis must be initiated before the uremic symptoms of peripheral neuropathy, encephalopathy, malnutrition, or serositis (including pericarditis) become evident (See Table 1).


Table 1. Clinical indications to initiate dialysis in patients with CKD. (7)
