A preponderance of evidence is sufficient.

Awareness of a problem is the first step toward finding solutions. The nephrology community is increasingly aware of the extraordinary morbid and mortal risks within the first year of renal replacement therapy (RRT), especially with in-center dialysis. However, this awareness has not yet been substantially translated to universal or even regional changes in care of patients—changes designed to address the recognized problems. Indeed, the trends associated with mortality and morbidity (hospitalizations) in dialysis forms of RRT have shown only minimal improvement in 20 years (1). The authors of the paper “Early Outcomes among Those Initiating Dialysis in the United States” (8) remind us again of the problem and its complexity and offer further insights into how caregivers of patients undergoing dialytic RRT might focus their efforts to improve outcomes in incident patients. A database of over 300,000 patients is compelling, although the analysis is both complex and observational. The analysis has its inherent weaknesses, as acknowledged by the authors. Two omissions seem deserving of comment. For one, the serum creatinine (and calculated estimated GFR [eGFR]) at the time of initiation of dialysis was not studied. Because many observational studies have linked higher eGFR at dialysis initiation (early start) with higher subsequent mortality risk, this omission limits the conclusions (2). This is an important point because during the period covered by this analysis, such an “early start” of dialysis contributed almost all of the overall growth in incident dialysis in the United States (3). Also, the modus of death was not studied (from death certificate acquisition); thus we can only speculate on the details for the mortal event (e.g., sepsis, myocardial infarction, congestive heart failure, etc). Nevertheless, this study clearly shows that incident dialysis patients are almost three times as likely to die in the first 2 weeks of care and are over twice as likely to enter the hospital compared with those who survive the first year of such therapy. This risk slightly lessens within the first 90 days and then begins to taper more rapidly. This is precisely the same observation suggested by a subset analysis of the United States Renal Data System (USRDS) (4). Even more concerning is the fact that 9% of deaths occurring in the first year do occur in first 2 weeks of dialytic treatment and 44% occur in the first 90 days. What is happening during this crucial period? More importantly, what might we do to alleviate this glaring problem of early postinitiation mortality and morbidity in dialysis patients? Examination of the details of the study provides some clues to the answers to these questions. Excess mortality and morbidity was associated with certain clinical practices: initiating dialysis with a fistula decreased early mortality by 61%, and starting patients with peritoneal dialysis decreased early mortality by 87%, although the latter effect did not persist. Although the picture is a rather gloomy one, areas worthy of a cheer are highlighted. Compared with 1997, there were slight improvements in 90-day and 1-year mortality. This was also confirmed by the USRDS (4). The lessons provided by this study, not provided by the USRDS observations, is that dicing and slicing the events into smaller temporal segments suggested associations with clinical patterns of care evolving over time, which might have a cause-andeffect relationship. Parenthetically, however, it is a bit shameful for our profession, or at least for me, that the improvements are so modest. Allow dispensation of the obvious. It is very possible that many of these patients should not have initiated dialysis in the first place. Elderly, infirm subjects with advanced renal failure may not receive benefits from dialysis RRT. Likely, for many patients, palliative nondialysis care would have been of more comfort to the patient and the family. Sicker and older patients are more likely to require indwelling vascular access catheters, perhaps even appropriately so, but at a cost of enhanced infection and sepsis (5). Indeed, the serum albumin concentration was lower in those who died earlier, confirming, in part, this observation of lesser health and visceral malnutrition and/or chronic inflammation. Information on eGFR at the onset of dialysis, as mentioned above, would have provided additional clues concerning somatic malnutrition, because eGFR in advanced renal failure is more a reflection of sarcopenia than residual renal function. Caregivers who initiate dialysis as a “trial” might contribute to these kinds of data. We lack information on how many patients for whom such socalled therapeutic interventions have failed. Subjectively, I suspect that it might well be in excess of 50% in the first year. In this regard, data from the USRDS show that those over the age of 65 have a first-year survival on dialysis of only 20%, suggesting that such high mortality risk is a surrogate for elderly and Department of Internal Medicine, Section of Nephrology; University of Texas Southwestern School of Medicine, Dallas, Texas; Department of Internal Medicine; Baylor University Medical Center, Dallas, Texas; and Renal Ventures Management, Golden, CO