Evaluation of DOQI guidelines: early start of dialysis treatment is not associated with better health-related quality of life. National Kidney Foundation-Dialysis Outcomes Quality Initiative

The National Kidney Foundation-Dialysis Outcomes Quality Initiative (DOQI) guideline, which is largely opinion based, promotes an earlier initiation of dialysis treatment than usual. Implementation of this guideline would require an expansion of dialysis capacity, leading to a considerable increase in costs. Such an expansion can only be justified by an improvement in patient outcome. We studied the effect of late versus timely initiation of dialysis treatment on the course of health-related quality of life (HRQOL) in new dialysis patients. As part of a large Dutch prospective multicenter study (Netherlands Cooperative Study on the Adequacy of Dialysis-2), we consecutively included all new patients with end-stage renal disease for whom residual renal function could be obtained 0 to 4 weeks before the start of dialysis therapy. HRQOL was assessed by means of the Kidney Disease and Quality of Life Short Form at regular intervals during the first year of chronic dialysis treatment. According to the DOQI guideline, 90 of the 237 included patients (38%) started dialysis treatment too late. All patients showed marked improvement in HRQOL during the first 6 months after the start of dialysis treatment. Compared with patients who started dialysis treatment too late, patients who started in time had significantly higher HRQOL for a number of dimensions immediately after the start of treatment. After 12 months of dialysis treatment, these differences had disappeared. An evidence-based recommendation on an early start of dialysis treatment is still difficult to give. In the short term, an earlier start resulted in better HRQOL. However, within 1 year, this advantage had disappeared. It is unclear whether this short-term benefit outweighs the extra restrictions associated with earlier initiation of dialysis therapy. Consequently, only the patient, in consultation with the nephrologist, is able to weigh both sides