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Cooper et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609-619. PMID 20581422

One-paragraph summary

IDEAL randomized 828 adults with progressive stage 5 CKD to planned dialysis at eGFR 10–14 or 5–7 mL/min/1.73 m² and followed them for median 3.59 years.

Key findings

  • Death: 37.6% early versus 36.6% late; HR 1.04 (95% CI 0.83–1.30). (Cooper 2010, PMID 20581422)
  • Median time to dialysis: 1.80 versus 7.40 months. (Cooper 2010, PMID 20581422)
  • 75.9% of the late group started above 7 because symptoms developed. (Cooper 2010, PMID 20581422)
  • Adverse-event frequencies did not differ significantly. (Cooper 2010, PMID 20581422)

Limitations

  • Achieved eGFR separation was small.
  • Symptoms appropriately drove protocol-permitted earlier starts.
  • Cockcroft–Gault was used for trial eGFR.

Why it matters

It displaced eGFR-only early initiation and supports a symptom/complication-triggered decision architecture.

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