Starting renal replacement therapy in end-stage renal disease patients

The main aim of this thesis was to contribute to the knowledge related to the start of renal replacement therapy in patients with end-stage renal disease. As a first objective we examined which clinical, social or logistical factors influence the decision-making of European nephrologists on whether and when to start renal replacement therapy. According to opinions of European nephrologists the preference and clinical condition of the patient are the two most important factors in their decision-making. Patient-centered studies are however required to explore which factors are important to the patients themselves and integrate this knowledge into shared decision-making processes. Subsequently, we aimed to study the associations of (non-)medical factors with dialysis modality choice in different patient groups and to examine dialysis modality specific patient survival and its trends in relation to changes in dialysis technique survival, dialysis modality choice and (pre-emptive) transplant rates in Europe. We concluded that also modality choice should rely mainly on patient preference, provided that contraindications for the dialysis modality of preference are absent. Survival outcomes on dialysis have been improving over the years, especially for patients treated with PD. Consequently, it is suggested that starting dialysis on PD results in the best survival outcomes for the majority of patients. Although the improved outcomes and the current burden on health care budgets plead for the expansion of PD use, the prevalence of PD in Europe has been decreasing since 2001. These results merit further investigation on how to stimulate the use of PD as initial dialysis modality in patients with end-stage renal disease