The Initiation of Renal-Replacement Therapy — Just-in-Time Delivery

Renal-replacement therapy for patients with end-stage renal disease was introduced approximately 50 years ago, yet the optimal timing for the initiation of dialysis is still debated. In recent years there has been a trend toward initiating dialysis at a relatively high estimated glomerular filtration rate (GFR),1,2 based on the assumption that starting dialysis early may avert the many medical and social problems associated with advanced uremia. For example, in 1996, only 19% of patients in the United States began dialysis therapy when the estimated GFR was higher than 10 ml per minute per 1.73 m2 of body-surface area (early . . .