DETRIMENTAL EFFECTS OF LATE REFERRAL IN PATIENTS WITH CHRONIC-RENAL-FAILURE - A CASE-CONTROL STUDY

Despite broader indications and easier access to renal replacement the rapy during the past decades in Western countries, an unduly high numb er of patients is still referred to maintenance hemodialysis (HD) at a very advanced stage of chronic renal failure (CRF). To assess whether such late referral induces detrimental effects, we retrospectively co mpared clinical status and laboratory features in 20 patients who had been referred to us less than one month prior to first HD (late referr al, or LR group) and in 20 sex- and age-matched controls who had under gone regular follow-up for at least six months prior to HD (early refe rral, or ER group). Male to female ratio was 12/8 and age averaged 53. 5 years in both groups. Mean (+/- 1 SD) systolic and diastolic blood p ressure were higher in LR group than in controls (180 +/- 14/102 +/- 1 0 vs. 153 +/- 15/86 +/- 7 mm Hg, P < 0.001) and fluid overload with pu lmonary edema was present in 13/20 versus 3/20 patients (P < 0.001). P lasma concentrations (mmol/liter) of creatinine (I. 12 +/- 0. 27 vs. 0 .97 +/-0.11, P < 0.01) and phosphate (2.58 +/- 0.47 vs. 1.92 +/- 0.31, P < 0.001) were higher, whereas plasma levels of bicarbonate (14.2 +/ - 3.9 vs. 22.5 +/- 4.2, P < 0.001) and calcium (1.85 +/- 0.24 vs. 2.27 +/- 0.15, P < 0.001) were lower in LR than in ER group, as were hemog lobin (7.1 +/- 1.1 vs. 9.4 +/- 0.9 g/dl, P < 0,001) and serum albumin levels (35.3 +/- 4.8 vs. 39.7 +/- 3.4, P < 0.01). In the LR group 15 p atients had to start HD in emergency conditions through central vein c atheterization for a mean duration of 32.1 +/- 10.3 days. Total durati on of hospitalization was 33.2 +/- 10.3 days in LR group versus only 5 .7 +/- 1.1 days in ER group (P < 0.001), resulting in a total cost of 4.34 versus 0.78 million francs. We conclude that patients referred at a very late stage of CRF without adequate nephrologic follow-up had m arkedly greater acidosis, hypocalcemia, hyperphosphatemia, anemia, hyp ertension and fluid overload than patients who benefited from regular follow-up, and they needed painful and costly measures to recover. Ear ly referral of CRF patients is beneficial and should be encouraged.