Timing of nephrology referral: Influence on mortality and morbidity

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 hemodi alysis program in Sainte-Marguerite University Hospital between January 1, 1989, and December 31, 1996. We excluded from the analysis five patients wi thout 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 9 3 patients (31%) had a late referral (LR) of less than 16 weeks before dial ysis. Short-time morbidity (initial emergent dialysis, pulmonary edema, sev ere hypertension, temporary vascular access placement for first dialysis, p rolonged initial hospitalization) was significantly more frequent in LR pat ients. Long-term evolution (mean follow-up, 26.5 +/-: 26 months) did not di ffer between the two groups. The number of days of hospitalization per pati ent-year at risk beyond the third month was 21.5 +/- 33.7 days for ER and 2 1.1 +/- 36 days for LR patients. Survival analysis showed no difference bet ween 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 surv ival rates were 52% in the ER and 56% in the LR group. In a Cox hazards reg ression model, referral pattern was not associated with a greater risk for death. In conclusion, delayed nephrology referral generated strikingly grea ter initial morbidity, but long-term outcome of hemodialysis patients was n ot modified by delayed nephrological care. (C) 2000 by the National Kidney Foundation, Inc.