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Kidney Int. 2019 Apr 12. pii: S0085-2538(19)30138-3. doi: 10.1016/j.kint.2019.01.017. [Epub ahead of print]

Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.

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University Health Network, University of Toronto, Ontario, Canada. Electronic address:
Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands.
Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milan, Milan, Italy.
University of Sydney, Sydney, NSW, Australia.
University Health Network, University of Toronto, Ontario, Canada.
Division of Nephrology, Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington, USA.
Kent Kidney Care Centre, East Kent Hospitals, University NHS Foundation Trust, Canterbury, Kent, UK.
Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China.
KDIGO, Brussels, Belgium.
University College London, London, UK.
Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
University of Sydney, Sydney, NSW, Australia. Electronic address:


Globally, the number of patients undergoing maintenance dialysis is increasing, yet throughout the world there is significant variability in the practice of initiating dialysis. Factors such as availability of resources, reasons for starting dialysis, timing of dialysis initiation, patient education and preparedness, dialysis modality and access, as well as varied "country-specific" factors significantly affect patient experiences and outcomes. As the burden of end-stage kidney disease (ESKD) has increased globally, there has also been a growing recognition of the importance of patient involvement in determining the goals of care and decisions regarding treatment. In January 2018, KDIGO (Kidney Disease: Improving Global Outcomes) convened a Controversies Conference focused on dialysis initiation, including modality choice, access, and prescription. Here we present a summary of the conference discussions, including identified knowledge gaps, areas of controversy, and priorities for research. A major novel theme represented during the conference was the need to move away from a "one-size-fits-all" approach to dialysis and provide more individualized care that incorporates patient goals and preferences while still maintaining best practices for quality and safety. Identifying and including patient-centered goals that can be validated as quality indicators in the context of diverse health care systems to achieve equity of outcomes will require alignment of goals and incentives between patients, providers, regulators, and payers that will vary across health care jurisdictions.


goal-directed dialysis; hemodialysis; home dialysis; initiation; modality; peritoneal dialysis; prescription; symptom control; vascular and peritoneal dialysis access


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