Acute renal failure: factors influencing nephrology referral and outcome

Abstract

We investigated the incidence, factors affecting referral and outcome of acute renal failure (ARF), in an unselected (predominantly Caucasian) population in the Grampian region of Scotland served by a single renal unit. Case-notes were examined for all patients with a serum creatinine > or = 300 mumol/l. ARF (311 patients) was defined as a temporary rise in serum creatinine > or = 300 mumol/l, or, if the patient died during the acute illness, clinical features indicating acute deterioration of previously normal renal function. Advanced ARF at presentation (51 of the 311 with ARF) was defined as a first recorded serum creatinine > or = 500 mumol/l. Patients were classified into low-, medium-, and high-risk groups according to presence of comorbidity and age. The annual incidence of ARF was 620/million population (pmp), that of advanced ARF 102 pmp. The age-related incidence of ARF ranged from 30 pmp in the age group (0-19 years) to 4266 pmp in the age group > 80 years. Overall, 22% were referred to a nephrologist (34% after excluding those with advanced cancer and age > 80 years). Referral of patients decreased from 100% in the age group 0-19 to 5% in those > 80 years. Referrals in the low-, medium- and high-risk groups were 75%, 30% and 14%, respectively. Patient survival at 2 years was 80%, 42% and 19% for low-, medium-, and high-risk groups, respectively (86%, 44% and 32% for referred patients). Referral and outcome in patients with ARF were significantly influenced by age and presence of comorbidity at presentation.

Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup

“…One element that has been examined is which physicians care for patients with AKI following hospital discharge. Studies indicate that most survivors of AKI are not cared for by nephrologists [89][90][91][92] . Although data derived largely from observational cohort studies suggest that referral to nephrology care is associated with improved survival 93 , causality remains to be proven and the elements of care that drive this potential benefit have not been identified.…”

Examination of Resource Use and Clinical Interventions Associated With Chronic Kidney Disease in a Managed Care Population

“…Data from multiple international studies have shown that delayed referral to a nephrologist is a significant problem and is associated with a higher prevalence of uremic complications at the initiation of dialysis, with increased hospitalization and higher cost of care. [21][22][23][24] In addition, Arora and colleagues demonstrated that incident dialysis patients who were referred late (defined as the first encounter with a nephrologist occurring within 4 months of dialysis initiation) were significantly more likely to have hypoalbuminemia and hypocalcemia and less likely to have received EPO and a permanent vascular access before the first hemodialysis. Late referrals to a nephrologist were also associated with lower levels of renal function at dialysis initiation, as documented by higher serum creatinine and a higher proportion of patients with predicted glomerular filtration rate <5 mL/min per 1.73 m 2 .…”

Incidence and Outcomes in Acute Kidney Injury

“…AKI is managed by a variety of specialities, renal wards, high-dependency wards, and intensive care units (ICU). A number of studies included ICU-treated patients (1)(2)(3)(4); others included only those with severe AKI (5,6) or included only those who required RRT (6 -8). Because AKI occurs more frequently in older people, the incidence of this condition is rising in accordance with demographic trends.…”