Follow the patient, not the number

As a nephrology fellow, I find it somewhat challenging to follow a patient with advanced CKD (eGFR, MDRD 8-10). However, I do find this process rewarding as it truly allows for the establishment of a substantial relationship with your patient. I follow the patient every 1-2 months and ask at each clinic visit if they are experiencing any uremic symptoms. Most of the time they say no and I go about performing an exam and review their labs. With the lack of randomized controlled trials to answer the question about what the optimal eGFR is to start renal replacement therapy we truly have to "listen" to the patient. However, as the symptoms of uremia are often insidious, a patient may not recognize how bad they really feel. I often wonder if I am putting a patient at risk by "waiting" for the development of uremic symptoms. Several recent observational studies have suggested that starting renal replacement therapy early may, in fact, be harmful.


Enter the IDEAL trial (Initiating Dialysis Early and Late). Published in the NEJM on June 27th, 2010. This trial randomized 828 patients (in Australia and New Zealand) with advanced CKD (cockcroft eGFR 10-15ml/min) into 2 groups according to when renal replacement therapy (RRT) is initiated.

1. Early RRT initiation group- 10-14 ml/min
2. Late RRT initiation group- 5-7 ml/min

However, the decision on when to initiate RRT was left to the discretion of the treating physician in the late initiation group. The primary outcome was death from any cause and secondary outcome were cardiovascular events, infections, quality of life and dialysis related complications. The patient population was mostly white (70%), male (64%), average age of 60, DM accounted for 1/3 of the ESRD, PD was the planned form of RRT initiation in 195 patients in the Early RRT group and 171 in the Late RRT group. Hemodialysis was the method in 188 in the Early RRT and 215 in the Late RRT groups. Both groups had been followed by a nephrologist for an average of 2.5 years before being enrolled in the study. Average creatinine at time of enrollment was 6 mg/dL.
There was no statistical difference in either the primary or secondary outcome in both groups. Interestingly 322 patients (76%) in the late RRT initiation group were started on some form of RRT secondary to mostly uremic symptoms or fluid overload before reaching an eGFR below 7.
(cockcroft gault/MDRD) eGFR at randomization and initiation of RRT-

• Early group start eGFR (13/9.8) --> 1.5 months average before initiation, eGFR (12/9)
• Late group start eGFR (13/9.9) --> 7.8 months average before initiation, eGFR (9.8/7.2)

In conclusion, I agree with editorial that accompanied this article. The majority of patients in the late group were initiated on RRT secondary to symptoms of uremia. Waiting for this to occur did not adversely affect the outcome in the late initiation group. Providing excellent pre-ESRD care to all patients with CKD is paramount. Getting timely access and providing medical therapy for complications of hypertension, fluid overload, electrolyte/acid-base derangements while listening closely to the patients symptoms of uremia, as we already do, seems to trump the lab value (in this case the estimated glomerular filtration rate). The decision to initiate renal replacement therapy needs to be individualized, not simply generalized by a lab number. Dr. Simon Prince has written a nice blog and video-blog piece on this article as well.