End-stage renal disease (ESRD) is preceded in most cases by a long and progressive decline in kidney function. Optimal management of patients with chronic kidney disease (CKD) usually requires the involvement of a nephrology specialist to address the complex issues that may arise, especially at the later stages of CKD.
Late referral of CKD patients to a nephrologist has been associated with adverse outcomes among ESRD patients. A recent study that was supported in part by the Agency for Healthcare Research and Quality (F32 HS00143) confirmed an association between late nephrologist referral (less than 4 months before starting dialysis) and a higher risk of death 1 year after initiation of dialysis.
Waqar H. Kazmi, M.D., of Tufts-New England Medical Center, and colleagues analyzed data from the Dialysis Morbidity and Mortality Study - Wave II to examine the impact of timing of nephrology care prior to dialysis on death within a year of starting dialysis. Of the 2,195 ESRD patients studied, 33 percent were referred late. Compared with patients in the late referral group, those in the early referral group (first nephrology visit 4 or more months prior to staring dialysis) were more likely to be white, have private or health maintenance organization insurance, be employed, married, and college graduates, and have diabetes as the cause of ESRD.
A hazards analysis demonstrated that compared with early referral patients, late referral patients had a 44 percent higher risk of death within a year after beginning dialysis. This higher risk remained significant after adjusting for other factors affecting risk of death such as age, race, coexisting conditions, and cause of CKD.
See "Late nephrology referral and mortality among patients with end-stage renal disease: A propensity score analysis," by Dr. Kazmi, Gregorio T. Obrador, Samina S. Khan, M.D., and others, in Nephrology Dialysis Transplantation 19, pp. 1808-1814, 2004.
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