Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients

Background. Late nephrological referral or chronic renal failure patients h as been shown to be associated with high morbidity and short-term mortality on dialysis. However. the impact of predialysis nephrological care duratio n (PNCD) on the long-term survival of dialysis patients had not been evalua ted. Methods. We studied data from all 1057 consecutive patients who started dia lysis treatment at the Necker Hospital from 1989 to 1998 (mean age at start of dialysis 53.8 +/- 17.2 years (range 18-91 years), excluding from analys is patients who presented with acute renal failure (n = 60) or advanced mal ignancy (n = 35). We evaluated the effects of PNCD and clinical risk factor s on all-cause mortality after long-term follow-up on dialysis. Results. Among the 1057 patients analysed (13.2%, diabetics), PNCD was < 6 months in 258 patients, 6-35 months in 267 patients, 36-71 months in 227 pa tients and <greater than or equal to> 72 months in 307 patients. Cardiovasc ular (CV) morbidity, namely a history of myocardial or cerebral infarction, peripheral arteriopathy, and/or cardiac failure, before starting dialysis was 39.6% and 37.4%, respectively, in patients followed for <6 months or 6- 35 months, compared with 24.4% in those followed for 36-71 months and 19.9% in those followed for <greater than or equal to> 72 months (P < 0.001). Fi ve-year survival was significantly lower in patients with a PNCD of < 6 mon ths (59 +/- 4.1%) than for 36-71 months or greater than or equal to 72 mont hs (77.1 +/- 3.7 and 73.3 +/- 3.6%, respectively, P<0.001), but similar to those followed for 6-35 months (65.3 +/- 3.9% NS). By Cox proportional haza rd analysis, PNCD <6 months., age, diabetes and prior CV disease were indep endent predictive factors of all-cause death on dialysis. Conclusions. This study provides suggestive evidence that longer duration o f regular nephrological care in the predialysis period. at least for severa l years prior to the start of dialysis. is associated with a better long-te rm survival on dialysis. Such data strongly support the argument for early referral and regular nephrological care of chronic renal failure patients.