Prevalence, Predictors, and Consequences of Late Nephrology Referral at a Tertiary Care Center

Abstract

Abstract. Despite improvements in dialysis care, mortality of patients with end-stage renal disease (ESRD) remains high. One factor that has thus far received little attention, but might contribute to morbidity and mortality, is the timing of referral to the nephrologist. This study examines the hypothesis that late referral of patients to the nephrologist might lead to suboptimal pre-ESRD care. Clinical and laboratory data were obtained from the patient records and electronic databases of New England Medical Center, its affiliated dialysis unit (Dialysis Clinics, Inc., Boston), and the office records of the outpatient nephrology clinic. Early (ER) and late (LR) referral were defined by the time of first nephrology encounter greater than or less than 4 mo, respectively, before initiation of dialysis. Multivariate models were built to explore factors associated with LR, and whether LR is associated with hypoalbuminemia or late initiation of dialysis. Of the 135 patients, 30 (22%) were referred late. There were no differences in age, gender, race, and cause of ESRD between ER and LR patients. However, there were significant differences in insurance coverage between these two groups. In the multivariate analysis, patients covered by health maintenance organizations were more likely to be referred late (odds ratio = 4.5) than patients covered by Medicare. Compared to ER, LR patients were more likely to have hypoalbuminemia (56% versus 80%), hematocrit <28% (33% versus 55%), and predicted GFR <5 ml/min per 1.73 m2 (17% versus 40%) at the start of dialysis, and less likely to have received erythropoietin (40% versus 17%) or have a functioning permanent vascular access for the first hemodialysis (40% versus 4%). It is concluded that late referral to the nephrologist is common in the United States and is associated with poor pre-ESRD care. Pre-ESRD care of patients treated by nephrologists was also less than ideal. The patient-, physician-, and system-related factors behind this observation are unclear. Meanwhile, pre-ESRD educational efforts need to target patients, generalists, and nephrologists.

Pre dialysis care and types of vascular access employed in incident hemodialysis patients: A study from Pakistan

“…Our study also highlights the importance of timely referral to nephrologist as shown in various studies. 24 - 26 Predialysis care was better in patients followed by nephrologist as most of them either had a functioning AV access or were advised AVF prior to starting HD and were aware of their renal status. This was also shown by Stehman Breen et al, 27 who found that patients informed of their kidney disease more than one year before beginning dialysis therapy were nearly three times as likely to have a fistula placed than those informed one to four weeks before dialysis therapy.…”

Rethinking quality in the context of persons with disability

“…Some authors suggest that clinical practice guidelines are useful in such situations, but may not address the full range of complexities that often occur [58]. Special treatment units focused on the specific disabling condition such as for spina bifida [59], stroke [60], or renal failure [61], may also help when the condition is uncommon.…”

Determinants of Urgent Dialysis Start in a Chronic Kidney Disease Cohort Followed by Nephrologists

“…We included patients with a minimum of 2 consultations; the mean number of consultations was 5.44 ± 2.35 during the year prior dialysis. Indeed, late referral has already been described as a major risk factor for UDS in several studies (7,8). This late referral is also associated with excess mortality(3); as an example in the meta-analysis of Chan et al in 2007, including 12 749 patients, the relative risk was 1.99 (95%CI [1.66-2.39] p < 0.0001)(8).…”