Elsevier

The American Journal of Medicine

Volume 124, Issue 11, November 2011, Pages 1073-1080.e2
The American Journal of Medicine

Clinical research study
Outcomes of Early versus Late Nephrology Referral in Chronic Kidney Disease: A Systematic Review

https://doi.org/10.1016/j.amjmed.2011.04.026Get rights and content

Abstract

Background

As late provision of specialist care, before starting dialysis therapy, is believed to be associated with increased morbidity and mortality, a systematic review was undertaken to evaluate clinical outcomes relating to early versus late referral of patients to nephrology services.

Methods

Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE were searched up until September 2008 for studies of early versus late nephrology referral in adult (>18 years) patients with chronic kidney disease. Early referral was defined by the time period at which patients were referred to a nephrologist.

Findings

No randomized controlled trials were found. Twenty-seven longitudinal cohort studies were included in the final review, providing data on 17,646 participants; 11,734 were referred early and 5912 (33%) referred late. Comparative mortality was higher in patients referred to a specialist late versus those referred early. Odds ratios (OR) for mortality reductions in patients referred early were evident at 3 months (OR 0.51; 95% confidence interval [CI], 0.44-0.59) and remained at 5 years (OR 0.45; 95% CI, 0.38-0.53), both P <.00001. Initial hospitalization was 8.8 days shorter with early referral (95% CI, −10.7 to −7.0 days; P <.00001). Differences in mortality and hospitalization data between the 2 groups were not explained by differences in prevalence of diabetes mellitus, previous coronary artery disease, blood pressure control, serum phosphate, and serum albumin. However, early referral was associated with better preparation and placement of dialysis access.

Conclusion

Our analyses show reduced mortality and hospitalization, better uptake of peritoneal dialysis, and earlier placement of arteriovenous fistula for hemodialysis with early nephrology referral.

Section snippets

Methods

A systematic review protocol (CD007333) was written and published in Issue 3, 2009 of the Cochrane Renal group.2 A systematic search was conducted to identify published studies of outcomes in patients with chronic kidney disease receiving dialysis, including timing of referral to nephrology services. Key search terms are listed in the supplementary electronic table (Table 1, online); no limits were used. The following databases were searched (search dates included): MEDLINE (1966 to September

Results

Our search identified 114 studies; 9 duplicate studies were removed and 14 were excluded based upon title or abstract. Full manuscripts of 91 papers were obtained and data were extracted from 27 studies; of the other 64 studies, 30 did not have relevant outcome measures, 19 were review articles, 6 were studies of acute renal failure, 5 were pediatric studies, and 4 did not meet our definition of early referral (Figure 1). The 27 included studies had 17,646 participants; 11,734 were referred

Discussion

Our meta-analysis showed that patients referred earlier to nephrology services had reduced mortality and hospitalization. The benefits seen in the earlier referred patients appear to be acquired independently of differences in traditional cardiovascular risk factors such as prior coronary artery disease, diabetes mellitus, systolic and diastolic blood pressures, lipid profile, and renal biochemistry. It appears that better fistula preparation and placement of dialysis access may explain

Conclusions

Patients referred earlier to a nephrologist demonstrate significantly reduced short- and long-term mortality, hospitalization, and anemia, as well as better dialysis preparation. Our data suggest that blood pressure, serum phosphate, and serum albumin appear to be managed equally by specialist and nonspecialist physicians. Neither did our analysis find any differences in the prevalence of comorbid illness often reported with late referral. Our analyses suggest that reduced mortality and

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Funding: The first author, Neil Smart, was funded by the Commonwealth Government of Australia's Department of Health and Aging Primary Healthcare Research Evaluation and Development program (2006-2009) during the time he undertook the work, with no influence on the study design, data collection, analysis, interpretation, or on the decision to submit.

Conflict of Interest: None.

Authorship: Both authors had equal access to data and contributed equally to the work and manuscript.

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