Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center

Despite improvements in dialysis care, mortality of patients with end-stage renal disease (ESRD) remains high. One factor that has thus far received l ittle attention, but might contribute to morbidity and mortality, is the ti ming of referral to the nephrologist. This study examines the hypothesis th at late referral of patients to the nephrologist might lead to suboptimal p re-ESRD care. Clinical and laboratory data were obtained from the patient r ecords and electronic databases of New England Medical Center, its affiliat ed dialysis unit (Dialysis Clinics, Inc., Boston), and the office records o f the outpatient nephrology clinic. Early (ER) and late (LR) referral were defined by the time of first nephrology encounter greater than or less than 4 mo, respectively, before initiation of dialysis. Multivariate models wer e built to explore factors associated with LR, and whether LR is associated with hypoalbuminemia or late initiation of dialysis. Of the 135 patients, 30 (22%) were referred late. There were no differences in age, gender, race , and cause of ESRD between ER and LR patients. However, there were signifi cant differences in insurance coverage between these two groups. In the mul tivariate analysis, patients covered by health maintenance organizations we re more likely to be referred late (odds ratio = 4.5) than patients covered by Medicare. Compared to ER, LR patients were more likely to have hypoalbu minemia (56% versus 80%), hematocrit <28% (33% versus 55%), and predicted G FR <5 ml/min per 1.73 m(2) (17% versus 40%) at the start of dialysis, and l ess likely to have received erythropoietin (40% versus 17%) or have a funct ioning permanent vascular access for the first hemodialysis (40% versus 4%) . It is concluded that late referral to the nephrologist is common in the U nited States and is associated with poor pre-ESRD care. Pre-ESRD care of pa tients treated by nephrologists was also less than ideal. The patient-, phy sician-, and system-related factors behind this observation are unclear. Me anwhile, pre-ESRD educational efforts need to target patients, generalists, and nephrologists.