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Invited Commentary
May 2018

Appropriate Time for Chronic Dialysis Initiation: A Cause for Humility

Author Affiliations
  • 1Department of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
  • 2Division of Nephrology, University of California, San Francisco
JAMA Intern Med. 2018;178(5):664-666. doi:10.1001/jamainternmed.2018.0470

The best time to initiate chronic dialysis in patients approaching end-stage renal disease (ESRD) is unclear. In this issue of JAMA Internal Medicine, Kurella Tamura and colleagues1 demonstrate the substantial variation in the initiation of dialysis among 11 215 older veterans with kidney failure (defined as sustained estimated glomerular filtration rate [eGFR]<15 mL/min/1.73 m2). They found that patients who exclusively used Medicare for pre-ESRD nephrology care had a 28 percentage point higher frequency of dialysis initiation and a 5 percentage point higher frequency of death compared with their counterparts who exclusively used the Veterans Affairs (VA) health care system for pre-ESRD nephrology care. These data extend prior reports regarding temporal and geographic variations in the likelihood and timing of dialysis initiation and add to previous studies finding that earlier initiation of dialysis is not associated with improved survival in many patients.2

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