LATE REFERRAL TO MAINTENANCE DIALYSIS - DETRIMENTAL CONSEQUENCES

Thirty per cent of patients who started maintenance haemodialysis at o ur institution between January 1989 and December 1991 had been referre d at a very late stage of their renal disease. To assess the causes an d consequences of such late referral we retrospectively compared clini cal and laboratory features of 65 patients who had been referred less than 1 month prior to first dialysis (late referral, or LR group) and of 153 patients who had been previously followed-up by us for more tha n 6 months (early referral, or ER group). Age, sex ratio, and socioeco nomic status were similar in the two groups. In the LR group, 38 patie nts had never been referred to a nephrology unit, whereas 27 had disco ntinued nephrological surveillance. Fluid overload, severe hypertensio n, and/or pulmonary oedema was present in 57% of LR versus 15% of ER p atients (P<0.001). Mean (+/- 1 SD) systolic and diastolic blood pressu re was greater in the LR than the ER group (173 +/- 19/99 +/- 12 versu s 147 +/- 15/84 +/- 8 mmHg, P<0.001). Mean plasma concentration of cre atinine, urea and phosphate was significantly greater, whereas bicarbo nate, calcium, haematocrit and albumin were less in the LR than the ER group. Most (88%) LR patients started dialysis in emergency condition s through central vein catheterization. Total hospital stay lasted 34. 5 +/- 16.3 days in LR versus 5.8 +/- 3.0 days in ER patients (P < 0.00 01), resulting in an excess cost of 0.2 million French francs per LR p atient. We conclude that patients referred at a late stage of renal fa ilure without previous nephrological follow-up had strikingly more sev ere uraemic disorders, together with poorer blood pressure control and clinical condition, than patients receiving adequate nephrological ca re, and needed prolonged hospitalization to recover. Such potentially avoidable deleterious effects strongly suggest the need for earlier an d closer co-operation between general practitioners and nephrologists.