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OBJECTIVE--To estimate the cost-effectiveness of surgically induced weight loss relative to conventional therapy for the management of recently diagnosed type 2 diabetes in class VII obese patients. RESEARCH DESIGN AND [...]

Screening young adults who are sexually active for genital Chlamydia trachomatisinfection is promoted in several high-income countries, but its effectiveness at the population level is highly debated. We aimed to investigate the effects of opportunistic chlamydia testing in primary care on the estimated chlamydia prevalence in the population aged 16–29 years in Australia.

♦ Background Since the mid-1990s, early dialysis initiation has dramatically increased in many countries. The Initiating Dialysis Early and Late (IDEAL) study demonstrated that, compared with late initiation, planned early initiation of dialysis was associated with comparable clinical outcomes and increased health care costs. Because residual renal function is a key determinant of outcome and is better preserved with peritoneal dialysis (PD), the present pre-specified subgroup analysis of the IDEAL trial examined the effects of early- compared with late-start dialysis on clinical outcomes in patients whose planned therapy at the time of randomization was PD.♦ Methods Adults with an estimated glomerular filtration rate (eGFR) of 10 – 15 mL/min/1.73 m2who planned to be treated with PD were randomly allocated to commence dialysis at an eGFR of 10 – 14 mL/min/1.73 m2(early start) or 5 – 7 mL/min/1.73 m2(late start). The primary outcome was all-cause mortality.♦ Results Of the 828 IDEAL trial participants, 466 (56%) planned to commence PD and were randomized to early start (n= 233) or late start (n= 233). The median times from randomization to dialysis initiation were, respectively, 2.03 months [interquartile range (IQR):1.67 – 2.30 months] and 7.83 months (IQR: 5.83 – 8.83 months). Death occurred in 102 early-start patients and 96 late-start patients [hazard ratio: 1.04; 95% confidence interval (CI): 0.79 – 1.37]. No differences in composite cardiovascular events, composite infectious deaths, or dialysis-associated complications were observed between the groups. Peritonitis rates were 0.73 episodes (95% CI: 0.65 – 0.82 episodes) per patient–year in the early-start group and 0.69 episodes (95% CI: 0.61 – 0.78 episodes) per patient–year in the late-start group (incidence rate ratio: 1.19; 95% CI: 0.86 – 1.65; p= 0.29). The proportion of patients planning to commence PD who actually initiated dialysis with PD was higher in the early-start group (80% vs 70%, p= 0.01).♦ Conclusion Early initiation of dialysis in patients with stage 5 chronic kidney disease who planned to be treated with PD was associated with clinical outcomes comparable to those seen with late dialysis initiation. Compared with early-start patients, late-start patients who had chosen PD as their planned dialysis modality were less likely to commence on PD.

Planned early initiation of dialysis therapy based on estimated kidney function does not influence mortality and major comorbid conditions, but amelioration of symptoms may improve quality of life and decrease costs.

Objectives The primary objective of the IDEAL study is to determine whether the timing of dialysis initiation has an effect on survival in subjects with end-stage renal disease (ESRD). The secondary objectives are to determine the impact of “early start” versus “late start” dialysis on nutritional and cardiac morbidity, quality of life, and economic cost.Design Prospective multicenter randomized controlled trial. Patients are randomized to commence dialysis at a glomerular filtration rate (by Cockcroft–Gault) of either 10 – 14 mL/minute/1.73 m2(“early start”) or 5 – 7 mL/min/1.73 m2(“late start”), with stratification for dialysis modality (hemodialysis vs peritoneal dialysis), study center, and the presence or not of diabetes mellitus.Setting Dialysis units throughout Australia and New Zealand.Patients Patients with ESRD commencing chronic dialysis therapy.Outcome Measures Three years from randomization, all-cause mortality, morbidity, and economic impact; structural and functional cardiac status, nutritional state, and quality of life will be assessed.Results To date, 388 patients of a minimum 800 patients have been entered and randomized into the study. Current recruitment rates suggest sufficient patients will be enrolled by December 2004 and follow-up completed by December 2007.Conclusions The IDEAL study will provide evidence for the optimal time to commence dialysis.