Continuum and Integration of Pre-Dialysis Care and Dialysis Modalities

T he principles of management of patients before dialysis and during dialysis have been well de scribed in the literature. The timing of the transition from pre-dialysis to dialytic care may be an important determinant of patient morbidity and mortality and has generated a great debate with the recent introduction by the National Kidney Foundation (NKF) of the U.S.A. Dialysis Outcomes Quality Initiative (DOQI) guidelines (1). Since the mid 1960s, dialysis is initiated based on several subjective symptoms, in conjunction with a few objective laboratory indices, which have their own limi-tations. Malangone et al found no association between the laboratory indices and the severity of symptoms and signs of uremia (2). Nephrologists have readily initiated dialysis when patients present with far advanced uremic symptomatology such as pericarditis, uremic encephalopathy, uremic neuropathy, pulmonary edema, hypertension, hyperkalemia, metabolic acidosis and gastrointestinal (GI) symptoms refractory to medical therapy considered as absolute indications (3). In the presence of the less severe symptoms and signs considered as relative indicators, nephrologists have often waited for the above-stated absolute indications to appear before initiating dialysis. Certain major problems arise with this approach. Bonomini et al as early as two decades ago showed that some of these uremic manifestations are irreversible (4). As the disease progresses, patients adapt their lifestyle to a decreased level of energy. Moreover, several studies have shown that delayed referral and subsequently later initiation of dialysis is associated with more severe metabolic abnormalities such as acidosis, ane-mia, hyperphosphatemia, and hypoalbuminemia (5-8), and with prolonged hospitalizations and costs (5-7,9),