Late referral and modality choice in end-stage renal disease

Background. We sought to determine whether late versus early referral to a nephrologist in patients with chronic kidney disease influences the initial choice of hemodialysis (HD) versus peritoneal dialysis (PD) or the likelih ood of switching treatment modalities in the first six months of therapy. Methods. Using New Jersey Medicare/Medicaid claims, all patients who starte d RRT between January 1991 and June 1996 and were diagnosed with renal dise ase more than one year prior to RRT were identified. In the resulting cohor t of 3014 patients, 35% had their first nephrologist consultation less than or equal to 90 days prior to initiation of dialysis. Results. After controlling for demographic characteristics, socioeconomic s tatus and underlying renal disease, age, black race [Odds ratio (OR) = 0.56 ], race other than black or white (OR = 0.56), and socioeconomic status (OR = 0.68) influenced the choice of initial treatment modality, but timing of the referral did not. However, patients starting on PD who were referred l ate were 50% more likely to switch to HD than were patients who saw a nephr ologist earlier [Hazard's ratio (HR) = 1.47]. In patients originally on HD, diabetic nephropathy (HR = 1.49) and black race (HR = 0.69) influenced the likelihood of switching to PD, but the timing of referral did not. Conclusions. These results refute earlier findings that late referral may l imit access to PD. We found that modality choice depends on factors such as age, race, or socioeconomic status, rather than on than timing of nephrolo gist referral. Late referral does not influence the likelihood to switch mo dality in patients starting on HD, but does so in patients starting on PD.