透析时机的选择

Optimal timing of dialysis therapy

终末期肾脏病（ESRD）患者通常会出现明显的临床症状。ESRD患者何时开始透析治疗是非常重要的问题。透析时机需要结合患者临床症状及肾小球滤过率（GFR）进行个体化的综合判断。ESRD患者出现尿毒症性心包炎或浆膜炎、尿毒症脑病和难治性的容量负荷过重等临床症状是开始透析治疗的绝对指征。肾功能下降至何种程度开始透析治疗，目前并无定论。近几十年国际上出现了对ESRD患者早期开始透析治疗的趋势。然而，观察性的研究发现早期开始透析的患者并未受益，相反，早期透析治疗加重了患者及其家庭以及整个卫生保健系统的负担。唯一一项前瞻性随机对照临床试验IDEAL研究发现，早期[GFR10～14ml·min-1·（1.73m2）-1]或晚期[GFR5～7ml·min-1·（1.73m2）-1]开始透析的患者在死亡率、生活质量等方面没有明显差异。根据现有证据，建议使用“意向性延迟”的策略指导透析时机的选择；不建议单独使用基于肌酐的估计GFR指导开始透析的时机，必须结合患者临床症状；单纯的营养状况下降及传统高风险人群（如糖尿病患者）无需早期透析治疗。

Patient with end stage renal disease （ESRD） usually presents overt clinical symptoms. The optimal time to initiatingdialysis in ESRD patients is addressed as the most important dialysis-related question. The timing of dialysis therapy should be individualized by the combination of clinical symptoms and the glomerular filtration rate （GFR）. Uremic pericarditis or pleuritis, encephalopathy, and refractory volume overload are the absolute indications for dialysis in ESRD patients. There is no minimum estimated GFR that provides an absolute indication to begin dialysis. There is a strong trend to early dialysis initiation for ESRD patients over the past decades. However, observational data found that early initiation seemed to produce no benefit but additional burden to patients and the health care system. The IDEAL study, the only prospective randomized controlled trial （RCT） research on this issue, found that there was no significant difference between early [GFR 10-14 ml·min-1·（1.73 m2）-1] and late [GFR 5-7 ml·min-1·（1.73 m2）-1] dialysis starters on mortality and quality of life. Based on current evidence, we recommend the intent-to-defer strategy to guide dialysis initiation and do not recommend to start dialysis using estimated GFR as an indication in the absence of symptoms. We do not recommend early initiating dialysis for patients with only declined nutritional status and for traditional high risk population （eg. diabetic patients）.