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Late referral to specialty care contributes to poor outcomes among patients with kidney failure

More than 300,000 Americans suffer from end-stage renal disease (ESRD, kidney failure) and must be treated with dialysis (renal replacement therapy) or kidney transplantation to survive. Patients who receive transplants have higher life expectancy, better quality of life, and consume fewer health care resources than those who remain on dialysis.

In two recent studies, investigators supported in part by the Agency for Healthcare Research and Quality (HS09398) examined the impact of late nephrologist referral (90 days or less before beginning dialysis) on the care of these patients. The first study found that late referral significantly reduced the likelihood of renal transplantation among ESRD patients. The second study revealed that ESRD patients referred to a nephrologist late were far more likely to have a central venous access (which is more prone to complications and infections) than a surgically created vascular access for hemodialysis than those seen by a nephrologist early. Both studies are summarized here.

Winkelmayer, W.C., Glynn, R.J., Levin, R., and others. (2002, June). "Late nephrologist referral and access to renal transplantation." Transplantation 73, pp. 1918-1923.

Older age, minority race, being female, and lower socioeconomic status all have been associated with reduced access of ESRD patients to renal transplantation. However, this study found that delayed referral of renal patients to a nephrologist significantly reduced the likelihood of renal transplantation, independent of these sociodemographic factors and the patients' coexisting medical conditions. The investigators examined New Jersey Medicaid and Medicare patients with new-onset chronic kidney dialysis, who had been diagnosed with renal disease more than 1 year before beginning dialysis. They matched 32 transplant recipients with 197 controls who shared the recipients' age, sex, race, and year of onset of dialysis but had not received a transplant on the index date (number of days from onset of dialysis to transplantation).

The researchers evaluated the impact of late referral, socioeconomic status, and coexisting conditions (comorbidity) in the year before the index date on likelihood of transplantation (either by living-related, living-unrelated, or cadaver donor). Late nephrologist referral was associated with a 78 percent lower rate of renal transplantation. Lower socioeconomic status was associated with 82 percent lower likelihood of transplantation. Finally, the likelihood of receiving a transplant declined by 31 percent for each one unit increase in a commonly used comorbidity index.

Seeing a nephrologist earlier during the course of chronic kidney disease probably speeds up the cumbersome process of being identified as medically suitable for a kidney transplant, having a pretransplantation workup, and ultimately being put on a waiting list to receive a transplant. Late referrals may be due to a cumbersome system, a lagging physician, or a reluctant patient. The overall prevalence of late referral of patients with chronic kidney disease in the United States has been estimated to be approximately 37 percent. This suggests a public health problem of major importance, which potentially could be avoided by provider and/or patient education and incentives, conclude the researchers.

Avorn, J., Winkelmayer, W.C., Bohn, R.L., and others. (2002). "Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure." Journal of Clinical Epidemiology 55, pp. 711-716.

Early nephrologist referral is essential for optimally preparing ESRD patients for kidney dialysis, according to this study. The nephrologist can intervene to retard progression of renal disease, effectively manage a patient's other medical conditions, adequately treat renal-based anemia and disturbances in metabolism, provide dietary education, and prepare the patient psychologically for dialysis and/or transplant. Early nephrologist referral also can ensure selection of an optimal time to establish a permanent vascular or peritoneal access for dialysis and appropriate initiation of the therapy.

Early referral makes it possible to surgically create a natural vascular access (fistula) that will be mature when hemodialysis begins and which is preferable to a prosthetic graft, since there is a lower rate of infection, less cost, and a higher patency rate (fistula stays open longer). Tunneled cuffed central venous catheters are an even more unfavorable alternative to prosthetic grafts because of their relatively poor blood flow and higher failure rate from thrombosis and infection.

If a patient is referred late to a nephrologist, there may not be sufficient time to create a natural fistula for kidney dialysis. As a consequence, catheters and/or grafts, which can be formed more immediately, are the likely alternative, explain the researchers.

They analyzed data from all health care encounters for New Jersey Medicare and Medicaid patients with ESRD between 1991 and 1996. These patients had been diagnosed with renal disease at least 1 year prior to onset of hemodialysis. Of the 2,398 hemodialysis patients identified, 35 percent had a late first nephrologist consultation. After controlling for demographic characteristics, socioeconomic status, and underlying renal disease, patients referred to a nephrologist earlier were 38 percent more likely to have undergone predialysis vascular access surgery. Similarly, patients who were referred late were 42 percent more likely to require temporary central venous access for dialysis.

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