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Symptom-Based Dialysis Initiation IDEAL Trial — ESENeph MCQ

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EasyChronic Kidney DiseaseSymptom-Based Dialysis Initiation IDEAL TrialESENeph

A 62-year-old woman with CKD G5 (eGFR 9 mL/min/1.73m2) develops restless legs, pruritus, persistent nausea, and weight loss over 3 months. Her nephrologist discusses options. She has good social support. Her KFRE 2-year risk of kidney failure is 85%. What is the OPTIMAL timing for starting RRT based on current evidence?

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Correct answer: D — Start dialysis based on symptoms and clinical indication rather than a specific eGFR threshold

The IDEAL trial (2010) demonstrated that early start of dialysis (eGFR 10-14) provided no survival benefit over a symptom-based approach (eGFR 5-7) but resulted in earlier dialysis-related morbidity. KDIGO 2024 and NICE NG203 recommend initiating dialysis based on SYMPTOMS and clinical indications (uraemic symptoms refractory to medical management, refractory fluid overload, hyperkalaemia, malnutrition, pericarditis) rather than a specific eGFR threshold. This patient has clear uraemic symptoms (restless legs, pruritus, nausea, weight loss) at eGFR 9 — these are indications to start RRT regardless of the eGFR number. Conversely, an asymptomatic patient at eGFR 9 may not need immediate RRT.

Reference: Cooper et al 2010 – IDEAL Trial; KDIGO 2024 – CKD Guideline; NICE 2021 – NG203