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Researchers examine why some patients with chronic kidney disease are referred late to a nephrologist

People suffering from chronic kidney disease (CKD)—either due to long-term diabetes, hypertension, or other problems—benefit greatly from early referral to a nephrologist. Late referrals (first nephrologist visit less than 90 days before the onset of renal dialysis) miss the opportunity to slow the progression of CKD and perhaps postpone the need for renal dialysis. They also are more likely than those referred earlier to die from kidney failure, be less ready for dialysis, have fewer options for dialysis, and have more hospitalizations.

According to a recent study, certain patients with CKD are more likely than others to be referred late to a nephrologist. The study was supported in part by the Agency for Healthcare Research and Quality (HS09398).

First author, Wolfgang C. Winkelmayer, M.D., Sc.D., and principal investigator, Jerry Avorn, M.D., of Brigham and Women's Hospital, and their colleagues developed a model to correlate specific demographic and clinical factors with delayed nephrologist referral for 3,014 Medicare- and Medicaid-insured adult patients in New Jersey. These patients began dialysis (renal replacement therapy) during the period 1990 through mid-1996 and had experienced renal insufficiency for more than a year before beginning dialysis.

Overall, 65.5 percent of the patients were referred to a nephrologist early. Patients who were 75 to 84 years of age were 73 percent more likely to be referred late compared with the reference group of 65- to 74-year-old patients. For patients aged 85 or older, this effect was even more pronounced. Black and white patients did not differ in referral patterns. However, people of other races were at nearly 70 percent greater risk for late referral, and men tended to be referred late compared with women.

CKD patients who had additional medical problems—hypertension, coronary artery disease, any cancer, and diabetes—were much less likely to have a late referral than people who did not. Doctors may be more likely to refer these patients early because they are aware of the relationship between certain diseases and CKD progression. They also tend to see CKD patients with coexisting medical problems more often and may have earlier opportunities to refer them to a nephrologist.

See "Determinants of delayed nephrologist referral in patients with chronic kidney disease," by Dr. Winkelmayer, Robert J. Glynn, Sc.D., Raisa Levin, M.S., and others, in the December 2001 American Journal of Kidney Diseases 38(6), pp. 1178-1184.

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