Original investigations: pathogenesis and treatment of kidney disease and hypertension
Impact of nephrology referral on early and midterm outcomes in ESRD: EPidémiologie de l’Insuffisance REnale chronique terminale en Lorraine (EPIREL): results of a 2-year, prospective, community-based study

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Abstract

Background: Most studies looking at how the outcome of end-stage renal disease (ESRD) is affected by the timing and quality of the care received before initiation of renal replacement therapy (RRT) are inconclusive. Methods: Five hundred and two adult French patients (age, 62.8 ± 16 years) receiving their first RRT were enrolled in a 2-year, community-based, prospective study. Subjects were assigned to 1 of 5 groups depending on the time between their first serum creatinine reading above 2 mg/dL (177 μmol/L): chronic renal failure (CRF) and nephrology referral (NR) and RRT. Multivariate logistic regression was used to analyze 90-day survival data, and data concerning long-term survival and inclusion on the waiting list for renal transplantation were analyzed using Cox proportional hazards regression. Results:Overall survival rates were 88% at 90 days, 77.2% at 1 year, 65.2% at 2 years, and 54.2% at 3 years. The nephrology referral pattern was associated with age and systolic blood pressure, and independently predicted early death. Compared with group 1 (NR > 12 months), odds ratios (confidence interval 95%) were 2.7 (1.2 to 6.3) for group 2 (NR ≤ 12 months or >4 months), 2.8 (1.0 to 8.0) for group 3 (NR ≤ 4 months or >1 month), 4.9 (2.2 to 11.0) for group 4 (NR ≤ 1 month; CRF > 1 month), and 5.2 (2.2 to 12.3) for group 5 (NR ≤ 1 month; CRF ≤ 1 month). Independent predictors of death in 90-day survivors were age, cardiac disease with previous episodes of heart failure, vascular disease, low diastolic blood pressure, and group 3 referral pattern. Not being entered on the waiting list for renal transplantation was predicted by age, diabetes, vascular disease, and nonelective first dialysis. Conclusion:Late nephrology referral is strongly associated with early death. Emergency first dialysis is an independent risk factor for not being placed on the waiting list for transplantation. Among 90-day survivors, referral pattern has little influence on mortality, which is mainly determined by cardiovascular complications at initiation of RRT.

Section snippets

Study design

Lorraine, 1 of 22 metropolitan administrative regions of France, is a mixed urban and rural area in the Northeast of the country. At the 1999 census, its total population was 2,306,827.13 Following an intensive briefing concerning the rationale of the study, all the for-profit (n = 2) and not-for-profit (n = 11) nephrology units in Lorraine agreed to participate (see Acknowledgment for details).

All consecutive patients with ESRD who had lived in Lorraine for at least 3 months and who were

Results

Five hundred and two adult patients (99.6% of them Caucasian) were included in the study. The annual average crude incidence of ESRD was 119 per million-population. With regard to analysis of early death (before day 90), the first RRT modality used was hemodialysis (HD) in 403 cases (80.3%), peritoneal dialysis (PD) in 88 (17.5%), and preemptive renal transplantation in 11 (2.2%). For analysis of late survival, the first RRT modality was considered to be that used at day 90: 325 patients

Discussion

This prospective, community-based study provides compelling evidence of a causal relationship between pre-ESRD medical care and outcome. It involved 100% of patients starting RRT in the Lorraine region over 2 years, corresponding to 92.4% of the area's incident ESRD cases. The data are therefore highly reliable and complete. Outcomes were prospectively recorded, and the very high level of completion can be expected to eliminate bias due to selective reporting. Efforts were made to enroll

Acknowledgements

The authors are indebted to all the nephrologists who actively participated in the study: Association Lorraine de Traitement de l’insuffisance rénale chronique: J. Chanliau, N. Cordebar, P.Y. Durand, J. Gambéroni, A.Mariot; CH de la SSM de Freyming—Merlebach: J.J. Haultier, J.M. Mittelberger; CH Metz-Thionville, Hopital Bonsecours: H. Terrasse, Ph. Mirgaine; Hopital Bel Air: P.L. Caraman, D. Visanica; Hopital Saint André et Association Saint André Metz: E. Azoulay, M. Galy-Floc’h, P. Gauthier;

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