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Sir, There have been several recent discussions around the timing of initiation of dialysis [1,2]. There remains little scientific consensus on when to start and on which clinical and biochemical parameters we base this decision. In the broadest sense, dialysis should serve to decrease morbidity and/or mortality whilst maintaining or improving quality of life. It is almost assumed that renal replacement therapy will offer this to all. However, an incident dialysis population is heterogeneous and failure to take this into account leads to nonindividualized generic care. We must therefore recognize that the optimal time to start dialysis may differ for varied patient sub-groups. Additionally, in those individuals who fail to thrive on dialysis, then withdrawal of therapy has to be considered. This group may further provide insight into those individuals for whom dialysis is altogether inappropriate. These questions are perhaps posed most often when we consider an elderly co-morbid patient with end-stage renal failure (ESRF). Following the introduction of dialysis it has been demonstrated that age correlates with symptom burden on renal replacement therapy [3]. UK Registry data reports a 50% mortality at 1 year in incident dialysis patients over the age of 85 years, with the greatest attrition rate being in the first 3 months [4]. This early mortality may negate any subsequent benefits from an early start. Furthermore, Williams et al. [5] examined 24 consecutive cases in which dialysis was felt to be inappropriate. It was found that even when a conservative approach is taken functional status could be maintained until death is imminent. The following short cases highlight the points that an ‘early start’ may not lead to maintenance, but to deterioration in quality of life. Also, that dialysis can be withdrawn in some with the realistic expectation of an improvement in symptoms and with the preservation of independence making it a viable therapeutic option.

Severe ascites following renal transplant biopsy caused by a rupture of a subcapsular lymphocele: treated successfully by retroperitonealization