Lack or insufficient predialysis nephrology care worsens the outcomes in dialyzed patients – call for action

Abstract

The phenomenon of patients with advanced renal failure accepted for dialysis at a late stage in the disease process (late referral [LR]) is known almost from the beginning of dialysis therapy. It may also be associated with worse outcomes. The aim of the study was to assess the effect of referral time on the outcomes, such as number of hospitalizations, length of stay, kidney transplantation, and mortality. A study of 1303 patients with end-stage renal failure admitted for dialysis in the same period in Fresenius Nephrocare Poland dialysis centers was initiated. The type of vascular access during the first dialysis was accepted as the criterion differentiating LR ( n = 457 with acute catheter) from early referral (ER; n = 846). The primary endpoint was the occurrence of death during the 13-month observation. By the end of observation, 341 (26.2%) of patients died. The frequency of death was 18.1 for ER and 37.9 for LR per 1000 patient-months. It can be estimated that 52.1% (95% CI: 40.5–61.5%) of the 341 deaths were caused by belonging to the LR group. Patients from LR group had longer hospitalizations, more malignancies, lower rate of vascular access in the form of a–v fistula, higher comorbidity index. It seems that establishing a nephrological registry would help to improve the organization of care for patients with kidney disease, particularly in the pandemic era.

Early referral to nephrological care improves long-term survival and hospitalization after dialysis initiation, independent of optimal dialysis start – a call for harmonization of reimbursement policies

“…The long-term effects of nephrological care before dialysis on hospitalization after dialysis initiation have not been well described. A recent cohort study of incident dialysis patients demonstrated lower hospitalization frequencies in the early referral group only during the first nine months after dialysis initiation [ 18 ]. However, the follow-up time was truncated at 13 months, and allocation to the early or late referral groups was based only on the presence of a CDC at dialysis initiation.…”

“…The timing of referral to a nephrologist and the level of nephrological care impact on morbidity and mortality, as well as the quality of life [ 4–9 ]. Late referral is also associated with a poorer condition, increased costs, and increased morbidity and mortality after dialysis initiation [ 10 -– 18 ]. However, it has been questioned whether predialysis nephrological care per se impacts clinical outcomes after dialysis initiation, in addition to an optimal dialysis start [ 19–21 ].…”

“…However, it has been questioned whether predialysis nephrological care per se impacts clinical outcomes after dialysis initiation, in addition to an optimal dialysis start [ 19–21 ]. This uncertainty may be a consequence of the limited number of databases covering the time before and after dialysis initiation [ 22 ], which has resulted in surrogate indicators of early referral in previous studies based on dialysis databases, for example, absence of emergency dialysis start [ 8 , 11 , 15–17 ], absence of registered nephrology visits in insurance databases [ 9 ], or dialysis initiation via a central dialysis catheter (CDC) [ 18 ]. Several of these criteria may cause considerable misclassification.…”

Patient engagement during the transition from nondialysis‐dependent chronic kidney disease to dialysis: A meta‐ethnography

“…The patients' goals and preferences regarding treatment modality and access should be incorporated into the medical consultation 8‐10 . However, transitional care during the peridialysis period is inadequate and can result in an unplanned or emergency initiation of dialysis 11,12 …”

“…[8][9][10] However, transitional care during the peridialysis period is inadequate and can result in an unplanned or emergency initiation of dialysis. 11,12 Patient engagement is defined as the desire and capability to actively participate in care in a way uniquely appropriate to the individual, in collaboration with healthcare providers, to maximize outcomes and improve the experiences of care. 13 Patient engagement reflects the core value of person-centred care, in which patients are encouraged to be actively involved in processing information, making and acting on decisions and managing self-care.…”