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The issue of the adequate or optimal time at which Serum calcium 2.3–2.5 mmol/l GFR ([Ccr+Clurea]/2) renal replacement therapy (RRT) should be initiated 10 ml/min/1.73 m2 for patients with advanced or terminal chronic renal Residual weekly Kt/Vurea 2 Serum phosphate <1.6 mmol/l Absence of fluid overload Serum PTH (1–84) failure (CRF) has been a matter of debate since the >60–<150 ng/ml very first introduction of this revolutionary therapeutic Blood pressure <140/90 mmHg Serum albumin >35 g/l concept, now close to 40 years ago, and is not yet Srum bicarbonate 22 mmol/l Hb concentration 10–12 g/dl settled. The lack of means of treatment, due mainly to Serum potassium <5.0 mmol/l MNCVa ( lower limb) >40 m/sec economic constraints, continues to play a key role in many areas of the world for retarding (or denying) RRT for a great number of patients with CRF. aMotor nerve conduction velocity. However the issue remains controversial in countries with good availability of therapeutic facilities, due The problem of measuring residual renal function either to inadequate medical management of many (RRF) patients prior to the ultimate stage of renal insufficiency or to conceptual/academic conflicts between different lines of thought set forward by defendants of ‘early Selecting the best, or perhaps only the least erroneous, dialysis’ versus challengers advocating the advantages indicator—altimeter—for measuring the level of RRF and safety of dietary restrictions for delaying to a is of course of key importance for selecting the strategy significant extent the initiation of dialysis treatment. to be applied to each individual patient. Serial measurements of serum creatinine concentration (Scr), or 1/Scr, or creatinine clearance (Ccr) per body surface area Late referral (BSA) are currently considered by many experts as less reliable parameters than the calculation of the residual glomerular filtration rate (GFR) according to The clinical status at the start of dialysis is a major factor among those involved in the vital and functional the formula: [Ccr+urea clearance (ml/min/1.73 m2)/2]. By compilation of 13 published reports grouping 115 prognosis of patients taken onto RRT [1]. Despite more intensive information provided to general practiobservations, Walser and Hill found that, on average, the ‘true’ GFR was indeed about 25% lower than the tioners and various categories of specialists pleading for an early referral of patients with even moderate measured Ccr [3]. The overestimation of the RRF based on the Ccr in patients with advanced CRF has renal insufficiency to competent nephrologists, it remains all too frequent that RRT is initiated either to be stressed and the use of a less imperfect indicator is highly recommended [4]. Similarly, the accuracy of in emergency situations, such as massive fluid overload and pulmonary oedema, or uncontrollable hypertenanother widely used indicator of RRF, as well as of ‘adequacy of dialysis’, Kt/V urea, is also open to sion or in patients who are severely debilitated due to malnutrition induced by anorexia and digestive sympcriticism due to the errors in evaluating the urea distribution volume (V ) in clinical practice. The clinical toms in relation with a severe uraemic state. Actually, ‘Dialysis should be initiated to promote wellness and estimation of total body water space (TBW, estimated at 55–58% of body weight) nor even the use of not to rescue from illness’ [2]. In many ways, a safe follow-up procedure for patients with advanced-stage sophisticated formulae based on anthropometric data (e.g. Watson formula) are universally accepted as reliuraemia can be compared with that applied for a smooth landing of an aircraft at a ‘Dialysis initiation able compared, for example, with results obtained with Bioelectrical Impedance Techniques [5]. airport’ using the navigation instruments listed in Table 1.

At which stage of renal failure should dialysis be started?