The National Kidney Foundation - Dialysis Outcome Quality Initiative (NKF-DOQI) guidelines suggest commencing dialysis when the Kt/V falls below 2.0 (GFR 10) unless the patient is completely free of uraemic symptoms and oedema and shows evidence of adequate nutrition.

If patients are to commence dialysis early then timely referral to a nephrologist is essential along with the appropriate pre-dialysis care and education so that the patient can make an informed choice of dialysis modality. In practice many patients are referred late and start dialysis within a few months of referral.

These patients most often receive haemodialysis as a first (default) treatment and rarely switch modalities thereafter. Other patients may be receiving follow up in nephrology clinics but still do not start dialysis in a timely fashion.

Recent unpublished data from our region suggests that:

		34% of patients are referred late and begin dialysis late;
		another 29% are referred appropriately but still begin dialysis late; and
		only 37% seem to achieve a planned start on a modality of their choosing with haemodialysis or peritoneal/dialysis access already in situ.

Possible advantages of an early start to dialysis are:

		preservation of residual renal function;
		improved cardiovascular status; and
		decreased hospitalisation and associated costs.

As residual renal function declines, incremental dialysis is required to maintain small solute clearances at adequate levels. Possible disadvantages include access failure and other dialysis related complications including burn out and resource consumption without benefit.

In the absence of controlled data, experiences from single center pilot studies may demonstrate the feasibility and patient acceptability of early start dialysis. We have analysed data on 32 patients who have commenced dialysis on 1 exchange of peritoneal dialysis, usually Extraneal™ overnight. The mean starting Kt/V was 2.09, and the median survival on one exchange was 540 days prior to requiring incremental dialysis with 3 patients not requiring any change in prescription for over 2 years (see graph below).

please click image to enlarge

All patients are still alive:

		11 are still receiving only one exchange (duration 1 - 21 months);
		13 have required incremental dialysis (after 1 - 31 months on a single exchange);
		five have been given renal transplants; and
		three are on haemodialysis.

Complication rates have been low with 2.6 hospital days per patient year while on 1 exchange and the frequency of bacterial peritonitis was only 2 episodes in 265 patient months (1 bowel perforation and 1 recognised contamination episode).

Conclusion
Our clinical experience demonstrates that in practice healthy start is acceptable and well tolerated by patients and seems to be associated with prolonged preservation of residual renal function at least in some patients. The complication and hospitalisation rates are low but only 15% of new patients over the last 3 years were suitable and agreed to participate in this study. Early referral to nephrology clinics and pre-dialysis education programmes may enable more patients to start dialysis at an appropriate time on a modality of their choice with access already insitu. This may then be associated with improved patient outcomes.