An update on the referral pattern of patients with end-stage renal disease

Abstract

This article first describes the epidemiology and reasons of late referal to the nephrologist of patients suffering from end-stage renal disease (ESRD). Depending on the definition, between 25 and 50% of worldwide ESRD patients are referred very late. Second, the relation of late referral to the quality of pre-ESRD care, its impact on the selection of dialysis modality, on the time of start of dialysis and on the use of an adequate vascular access, are discussed. Finally, the economic aspects of late referral are described and ways to improve the referral pattern are proposed.

Peritoneal Dialysis and the Process of Modality Selection

“…Patients starting dialysis urgently are considered less likely ever to do PD, which may become a self-fulfilling prophecy if they continue to be thought of as "non-ESRD" for weeks or months on end and are not encouraged to enter a modality education process (9). We would argue that those patients should be considered candidates for modality selection at a much earlier stage.…”

“…Ideally, this assessment will have been made in the CKD clinic, long before initiation of dialysis. However, early assessment will not have occurred in the large proportion of patients who start dialysis urgently (9)(10)(11). In that group, the assessment will typically have to start after dialysis initiation.…”

Early Requirement for RRT in Children at Presentation in the United Kingdom: Association with Transplantation and Survival

“…LR in adults is common with estimates of between 20% and 50% (10)(11)(12)(13)(14)(15), and has been shown to adversely affect dialysis access (3,7,9), hemoglobin levels (3,4,9), and choice of modality at the start of RRT (3,5,8), as well as being associated with poorer survival (4,5,7,9) and prolonged hospital stay (8). LR will also delay listing for transplantation as work-up is delayed and reduce the chance of pre-emptive transplantation (16,17).…”

Clinical research of kidney diseases II: problems of study design

“…Lead-time bias occurs when diagnosis is made earlier than usual in a group of patients, independently of disease progression, such as in early referrals [7]. Measuring survival from dialysis initiation makes prognosis appear better in those who started dialysis with better renal function [8].…”