Original Investigation
Timing of nephrology referral: Influence on mortality and morbidity*,**

https://doi.org/10.1053/ajkd.2000.8241Get rights and content

Abstract

To assess the influence of the timing of nephrology referral on the short- and long-term outcome of hemodialysis patients, we retrospectively studied 309 patients who had end-stage renal failure and entered the chronic hemodialysis program in Sainte-Marguerite University Hospital between January 1, 1989, and December 31, 1996. We excluded from the analysis five patients without available data on referral pattern and 34 patients with irreversible acute renal failure. Of the remaining 270 patients, 177 patients (58%) had an early referral (ER) 16 or more weeks before the start of dialysis, and 93 patients (31%) had a late referral (LR) of less than 16 weeks before dialysis. Short-time morbidity (initial emergent dialysis, pulmonary edema, severe hypertension, temporary vascular access placement for first dialysis, prolonged initial hospitalization) was significantly more frequent in LR patients. Long-term evolution (mean follow-up, 26.5 ± 26 months) did not differ between the two groups. The number of days of hospitalization per patient-year at risk beyond the third month was 21.5 ± 33.7 days for ER and 21.1 ± 36 days for LR patients. Survival analysis showed no difference between the two groups: 3-month survival rates were 96% in both groups, 1-year survival rates were 90% in the ER and 89% in the LR group, and 5-year survival rates were 52% in the ER and 56% in the LR group. In a Cox hazards regression model, referral pattern was not associated with a greater risk for death. In conclusion, delayed nephrology referral generated strikingly greater initial morbidity, but long-term outcome of hemodialysis patients was not modified by delayed nephrological care.

Section snippets

Patients and methods

We retrospectively studied the medical records of 309 patients with end-stage renal failure who entered the hemodialysis program in Sainte-Marguerite University Hospital (Marseille, France) for the first time between January 1, 1989, and December 31, 1996. Information on the timing of nephrology referral before dialysis was available for 304 patients and was used to assign patients to two groups. Patients were considered early referral (ER) if they were referred to a nephrologist at least 16

Clinical characteristics of patients

Among the 270 patients who entered onto the study, 177 patients (66%) were referred early, at a mean of 244 ± 277 weeks (4.7 ± 5.3 years) before the start of dialysis (range, 16 weeks to 31 years; median, 142 weeks), and 93 patients (34%) were referred late, at a mean of 1.75 ± 2.7 weeks before the start of dialysis (range, 0 to 13 weeks; median, 0 weeks). The rate of patients referred late was the same (30%) in 1989 and 1996. Table 1 shows the demographic characteristics of patients and

Discussion

Late nephrology referral is a common problem and is frequently associated with greater initial morbidity or mortality.1, 16 The aim of our study is to assess the influence of the timing of nephrology referral on long-term morbidity and mortality in our hemodialysis population.

Initial complications were strikingly greater in patients with a late nephrology referral. The need for initial emergent dialysis and temporary central venous catheterization and uremia-related complications, such as

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    *

    Received May 17, 1999; accepted in revised form February 25, 2000.

    **

    Address reprint requests to Yvon Berland, MD, Service de Néphrologie et Hémodialyse, Hôpital Sainte Marguerite, 270 Boulevard de Sainte Marguerite, 13009 Marseille, France. E-mail: [email protected]

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