Optimal Referral to Pre-Dialysis Services: One Center's Experience

Abstract

The number of patients receiving renal replacement therapy in the United Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public health problem with significant comorbidity and mortality. Several organizational guidelines have been developed in an attempt to identify when appropriate referral to nephrology services should occur; however, many of these guidelines provide conflicting recommendations on referral. Recent surveys suggest that more than 30% of patients with CKD are referred later than the ideal. Late referral of patients with CKD is associated with increased patient morbidity and mortality, increased need for and duration of hospital admission, and increased initial costs of care following commencement of dialysis. Benefits of early referral include the identification and treatment of reversible causes of renal impairment and management of the multiple coexisting conditions associated with CKD. Referral time also affects the choice of modality of treatment. Patients and their families should receive sufficient information regarding the nature of their CKD and options for treatment so that they can make informed decisions concerning their care. Literature addressing the timing of referral to low-clearance or pre-dialysis clinics is limited. Existing data suggest that such clinics and patient education programs may improve the medical care of patients, promote greater patient involvement in the selection of the mode of dialysis, reduce the need for “urgent start” dialysis, and improve short-term survival and quality of life after initiation of dialysis. Audit of our pre-dialysis clinic has demonstrated improved patient outcomes, and we view this service as an essential component of the patient pathway.

Family income is associated with quality of life in patients with chronic kidney disease in the pre-dialysis phase: a cross sectional study

“…Hence, some studies have shown that quality of life (QOL), assessed by internationally validated questionnaires, is worse in individuals with CKD compared to those without renal disease [ 10 ], and that the morbidity and mortality in end-stage disease are influenced by timing and quality care before the start of dialysis [ 8 , 11 ]. A systematic review of the QOL scores of these patients as a parameter of treatment adequacy is recommended [ 1 ] and it is also suggested that interventions in pre-dialysis are useful and can influence the clinical evolution in the later stages of the disease [ 1 , 8 ].…”

Impact of Break-In Period on the Short-Term Outcomes of Patients Started on Peritoneal Dialysis

“…Some researchers suggest delaying PD for 4 - 6 weeks after catheter insertion to accelerate wound healing (8). However, quite a few patients have to start urgently on dialysis because of late referral or unexpected deterioration of residual renal function (9,10). Currently, the optimal duration of the break-in period is still unclear.…”

“…34, no. 1 PDI Patients were grouped according to the duration of their break-in period (from catheter implantation and to dialysis initiation): 7 days or less (BI ≤7 ), 8 -14 days (BI [8][9][10][11][12][13][14], and more than 14 days (BI >14 ).…”

Predialysis nephrology care amongst Palestinian hemodialysis patients and its impact on initial vascular access type

“…Early nephrology referral has been associated with multiple advantages, including improved outcomes [45][46][47][48], financial cost of emergent dialysis, psychosocial preparation and modality choice of initial dialysis [49]. In addition, early referral may be associated with slowing of the progression of ESRD, decreasing the need for and duration of hospital admission, higher albumin, relatively lower phosphorus and parathyroid hormone levels, choice of peritoneal dialysis modality and improved quality of life [31,44,45,[50][51][52][53]. Data from a previous prospective cohort study that conducted between 2002 and 2006, suggested that the anemia and progression of left ventricular hypertrophy in the late referral patients during HD treatment are associated with poor survival on HD [54].…”