Referral pattern fof hemodialysis patients to nephrologists.

Abstract

To determine the referral pattern of dialysis patients to nephrologists and the effects of late referral on clinical, hematological and biochemical parameters in patients presenting for the first-time to dialysis center. Cross-sectional study. Hemodialysis Unit of Shalamar Hospital, Lahore, from June 2003 to October 2006. This study was conducted on all patients of end stage renal diseases presenting for the first-time for undergoing hemodialysis at our center. Patients with acute renal failure were excluded from the study. At presentation, a history was taken from all the patients regarding seeking of nephrology services and referral pattern. Early and late referral was defined as the time of first referral or admission to a nephrologists greater or less than six months respectively before initiation of hemodialysis. All the patients were examined and their blood sample was drawn at the same time for routine hematological, biochemical parameters (urea, creatinine, serum potassium, calcium, phosphate and albumin) and viral markers (Anti HCV and HbsAg). In this study, 248 patients were enrolled, amongst them, 131 (52.8%) were male and 117 (47.2%) were female. Major causes of renal failure were diabetes mellitus, chronic glomerulonephritis and hypertension. Most of the patients were euvolemic and hypertensive. Sixty percent of patients were having very high urea ( > 200 mg/dl) and creatinine ( > 8.0 mg/dl). Most of the patients, 226 (91.1%), were anemic (Hemoglobin < 11gm/dl) and 224(90%) were hypoalbuminemic (serum albumin<4gm/dl) on first presentation. Majority of patients were hyperkalemic, 139 (56.0%), hypocalcemic, 168 (67.7%) and serum phosphate level was high in only 117 (47%) patients. All the patients presented in emergency room to nephrologists at very late stage (100% late referral), when disease was very much advanced. All of them did not have permanent vascular access for hemodialysis on first presentation to dialysis center. Reasons for late referral were non-availability of nephrologists and nephrology services, non-renal doctors biased, unawareness and training of medical professionals for these patients, patients' own denial for dialysis, fear and wrong perception about dialysis procedure, socioeconomic factors and use of non-evidenced based treatment modalities.