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EQUAL – Background

In patients of 65 years and older with end-stage renal disease (ESRD), dialysis is usually started at a renal function, as indicated with estimated glomerular filtration rate (eGFR) of 5 to 15 ml/min/1.73m2. Over the past decade, there has been a trend to start dialysis at higher levels of eGFR to make a so-called ‘healthy start’. Patients above 75 years old are starting dialysis more than half a year earlier than members of the same age group did in the past

From the patients perspective, it is suggested that in some countries a substantial number of elderly patients wish to postpone dialysis (or prefer not to start dialysis at all). With adequate prescription of relevant medication and diet dialysis might indeed be safely postponed or even not started in elderly ESRD patients as for specific patient groups the burden of dialysis may be bigger than the benefit.

The best timing of starting dialysis is unknown when considering patient survival and quality of life. Additionally, we don’t know whether starting dialysis in patients with a high or low renal function and starting with high versus low number of signs and symptoms is better.

Insight in the decision making process regarding ESRD care involving both nephrologists and patients is currently lacking. In addition, there is no agreement on a valid method to measure renal function in advanced chronic kidney disease (CKD) to decide when to start dialysis as there is considerable doubt whether the eGFR, and other serum creatinine-based measures of renal function can be used because of their inaccuracy and imprecision to reflect residual renal function in this stage of the disease.

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