Impact of Early versus Late Referral to Nephrologists on Outcomes of Chronic Kidney Disease Patients in Northern India

Abstract

Background. CKD patients are often asymptomatic in the early stages and referred late to nephrologists. Late referred patients carry a poor prognosis. There is a lack of data on outcomes associated with referral patterns in CKD patients from northern India. Methods. In this observational cohort study, all CKD patients who visited the nephrology OPD of the institute between Nov 1, 2018, and Dec 31, 2020, were classified as early referral (ER) if their first encounter with a nephrologist occurred more than one year before initiation of dialysis and education about dialysis (from a nurse or nephrologist). The remaining others were considered late referrals (LRs). The outcomes impact of early and late referrals was analyzed. Results. A total of 992 (male 656) CKD patients (ER, n = 475 and LR, n = 517) were enrolled. Patients referred early were older and diabetic and had higher BMI, better education, occupation, and socioeconomic status as compared to those referred late. The mean eGFR at first contact with the nephrologist was (25.4 ± 11.5 ml/min) in ER and 9.6 ± 5.7 ml/min in the LR group and had a higher comorbidity score. The CKD-MBD parameters, hemoglobin, and nutritional parameters were worse in LR. Only a few patients had AVF, and the majority required emergency dialysis in the LR group. A total of 91 (9.2%) patients died, 17 (1.7% ER and 74 (7.5%) patients in the LR group patients. There was significantly lower survival at 6 months (ER 97.1% vs. LR 89.7%), 12 months (ER 96.4% vs. LR 85.7%), 18 months (ER 96.4% vs. LR 85.7%), and 24 months (ER 96.4% vs. LR 85.7%) in late referral group as compared to early referral group P = 0.005 . Conclusions. LR to nephrologists has the risk of the emergency start of dialysis with temporary vascular access and had a higher risk of mortality. The timely referral to the nephrologist in the predialysis stage is associated with better survival and reduced mortality.

Factors Impacting the Referral Time to Nephrologists in Chronic Kidney Disease Patients in South Punjab, Pakistan

“…On the other hand, patients who were smokers and had congestive heart failure were associated with early referral. The cause of kidney disease also determines the referral time as glomerulonephritis is always referred to early worldwide as this disease is associated with the nephrology department (Caro Martínez et al, 2019;Dhanorkar et al, 2022;Greer et al, 2019).…”

Epidemiology and referral patterns of patients living with chronic kidney disease in Johannesburg, South Africa: A single centre experience

“…Such late referrals appear more frequent in the developing world, possibly reflecting poorer access to specialist nephrology services. In India and Brazil, which share BRICS organization membership with South Africa, late referrals account for 52 and 58% of dialysis initiations, respectively [ 44 , 45 ]. Data from the African context is lacking, but previous reports suggest that 50% of CKD patients in Nigeria manifest indications for urgent dialysis initiation at referral [ 46 ].…”

Nephrology referral slows the progression of chronic kidney disease, especially among patients with anaemia, diabetes mellitus, or hypoalbuminemia: A single‐centre, retrospective cohort study

“…Nephrology referral may lead to a more comprehensive nutritional evaluation and intervention aimed at improving overall nutritional status. Improved nutritional status may have a positive impact on overall health and may slow the progression of CKD 20 . More aggressive blood pressure‐lowering therapy is effective in preventing CKD progression 21 .…”

“…Improved nutritional status may have a positive impact on overall health and may slow the progression of CKD. 20 More aggressive blood pressure-lowering therapy is effective in preventing CKD progression. 21 However, adjustment for the use of antihypertensive medications did not change the results substantially.…”