Context

Initiation of dialysis in patients with chronic kidney disease will depend on a combination of biochemical parameters and/or the development of symptoms and signs of uraemia. Waiting for some of these clinical events may well place the patient in jeopardy. This concern, in addition to a number of cohort studies,1 2 lead to the opinion-based guidelines to initiate chronic dialysis at a predefined, ‘early’ level, based on calculated glomerular filtration rate (GFR).3 The consequence of these recommendations resulted in a doubling, between 1996 and 2005, of patients started on chronic dialysis with an estimated GFR >10 ml/min. The impact of this phenomenon on morbidity and mortality has been debated.4 5 The IDEAL (Initiating Dialysis Early and Late) study was designed to answer this important clinical decision-making dilemma.