Early versus tate referral for end-stage renal failure: role of the nephrologist.

Purpose. - As patients with chronic renal failure are frequently referred l ate to nephrologists, we decided to quantify the magnitude of late referral and its consequences. Methods. - We studied retrospectively an inception cohort of 62 patients st arting dialysis (either hemodialysis or continuous ambulatory peritoneal di alysis) during 1993 with a 4-year follow-up. Results. - The mean delay between either first symptoms of renal disease, o r first evidence of renal failure and nephrologist referral was 10 years an d 3 years 56 days, respectively. About 47% of the patients were referred le ss than 6 months before starting dialysis, and 27.5% less than 1 month. Blo od pressure levels were higher in patients referred less than 6 3 and 1 mon th (P < 0.05), as was creatinine concentration in patients referred less th an 1 month (P < 0.05). In contrast, plasma calcium was lower for referral l ess than 6 months (P < 0.05) and 3 months (P < 0.005), as was bicarbonate c oncentration for referral less than 3 and 1 month (P < 0. 05). Initial hosp italisation stay was prolonged (x 1.5) for late referral less than 3 months (56.4 +/- 39 days vs 35.9 +/- 33.6 days, P < 0.05) as was 6 months hospita lisation lengh for referral less than 3 months (x 1.6) (52.9 +/- 40.6 days vs 33.2 +/- 28.7 days, P < 0. 05) and less than 1 month (x 1.8) (61 +/- 45 days vs 33.9 +/- 28. 7 days, P < 0. 05) and < 1 month (x 1.8) (61 +/- 45 da ys vs 33.9 +/- 28. 7 days, P < 0.05). Only 44.1% of patients started hemodi alysis with a functioning arteriovenous fistula, and patients requiring tem porary access had a 4.4-fold longer initial (60.1 +/- 41.7 days vs 13.6 +/- 11.6 days, P < 0. 005) and 6-month (59.6 +/- 39 days vs 13.6 (9.1, P < 0.0 05) hospitalisation stay. The four-year mortality rate was unaffected by th e delayed referral but strongly and independently predicted by age, diabeti s and hypoalbuminemia. Conclusion. - Early nephrologic referral and timely initiated dialysis decr ease morbidity at the start of dialysis and both hospitalisation length and costs. (C) 2001 Editions scientifiques et medicales Elsevier SAS.