When to start dialysis
The key issue here is not simply whether dialysis is started โtoo early,โ but what is driving that decision. The article points to a health-system pattern: when outpatient kidney care is hard to access, dialysis may become the most reliable way to keep a person engaged in treatment. That makes the finding important, but it also means the study is describing an association, not proving that more clinics directly cause earlier dialysis in every case.
For readers, the practical takeaway is that timing decisions are shaped by more than kidney numbers alone. Appointment availability, missed visits, transportation, insurance structure and clinic capacity can all influence when a patient reaches dialysis. Those factors are easy to overlook if the discussion focuses only on laboratory results or disease stage. In real life, the โbestโ moment to start dialysis may reflect both medical need and the support a patient can realistically receive before reaching that point.
This also raises a trade-off that matters for prognosis and quality of life. Dialysis can prolong life for people with advanced kidney failure, but it is also time-intensive and disruptive. If pre-dialysis care is under-resourced, patients may lose time that could have been spent stabilizing kidney function, managing symptoms and planning for the transition in a less rushed way. The broader lesson is that access to care can influence outcomes before dialysis ever begins.
That makes the article relevant beyond nephrology. It highlights how system design can shape treatment pathways, especially for chronic disease. For patients and families, the important question is not only โWhen is dialysis indicated?โ but also โWhat support is available to delay it safely, if possible?โ
When to dialyze?
Treating people with chronic kidney disease is logistically challenging โย just ask Ladan Golestaneh, a nephrologist in the Bronx. She has to see some of her patients every few weeks to adjust medications and keep their kidneys functioning.
But sometimes, patients donโt show up to their appointments. Other times, Golestaneh doesnโt have any open slots. Peopleโsย disease gets worse, and they might have to get put on dialysis โย an outcome that could have been delayed or prevented if they got the medical care they needed.
โThis is actually a very frustrating problem,โ she says.
Dialysis isย an expensive and inconvenient treatment given to more than half a million Americans. But sometimes, itโs easier for doctors to put their patient on dialysis โย where theyโll be getting more consistent care โย rather than continuing to try to treat them in the office.
Thatโs one of the implications of a paper that Golestaneh, also a professor of medicine at Montefiore Medical Center in New York City, and her colleagues published last week in JAMA Network Open. Doctors may be sending patients to dialysis early because they donโt have the time or resources to keep taking care of the patients themselves, Golestaneh says.
The paper found that people living in areas with more dialysis clinics tendย to start dialysis earlier than people living in places with fewer clinics.
โWhat itย represents is the lack of ability of health systems to really keep a close eye on the sickest patients,โ Golestaneh says.
Dialysis can beย taxing andย time-consuming, requiringย several hours-long weekly appointments at a dialysis center. โItโs like a part-time job,โ Golestaneh says. And itโs expensive โย Medicare, which pays for most of dialysis, shells out an average of $90,000 a yearย per patient.
To make time and resources more available to patients, Golestaneh says that government insurance programs like Medicare shouldย financially incentivize health systems to keep patients healthier and not put them on dialysis. The government is working on this through experimental programs that Golestanehโsย medical center is a part of.
The health-care system could save money โย and people with kidney disease might live longer without the disruptions of dialysis โย if patients had more access to that health care, she says.
โIf I could wave my magic wand,โ saysย Golestaneh, sheย would ask for more pre-dialysis care in order to helpย โdelay the need for dialysis as much as possible.โย โย Ike Swetlitz
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