Late Referral Patients Research Articles

Surgical Treatment for Isolated Tricuspid Valve Disease: A Less Invasive Approach for Better Outcomes.

Background. Severe tricuspid valve (TV) disease has a strong association with right ventricle dysfunction, heart failure and mortality. Nevertheless, surgical indications for isolated TV disease are still uncommon. The purpose of this study is to analyze outcomes of patients undergoing minimally invasive isolated TV surgery (ITVS). Methods. Data of patients undergoing right mini-thoracotomy ITVS were prospectively collected. A subgroup analysis was performed on late referral patients. Five-year survival was assessed using the Kaplan-Meier survival estimate. Results. Eighty-one consecutive patients were enrolled; late referral was recorded in 8 out of 81 (9.9%). No cases of major vascular complications nor of stroke were reported. A 30-day mortality was reported in one patient (1.2%). Five-year Kaplan-Meier survival analysis revealed a significant difference between late referral patients and the control group (p = 0.01); late referral and Euroscore II were found to be significantly associated with reduced mid-term survival (p = 0.005 and p = 0.01, respectively). Conclusions. To date, perioperative mortality in patients undergoing ITVS is still consistently high, even in high-volume, high-experienced centres, and this accounts for the low rate of referral. Results from our report show that, with proper multidisciplinary management, appropriate pre-operative screening, and allocation to the safest approach, ITVS may offer better results than expected.

MO694: Analysis of Mechanical Complications in Urgent-Start Peritoneal Dialysis

Abstract BACKGROUND AND AIMS Peritoneal dialysis (PD) is an excellent, but underutilized dialysis technique. Thus, its implementation might depend on the chance to offer this modality of treatment to late referral patients. This approach has been recently named ‘urgent-start peritoneal dialysis’ (UPD). The major barrier to this practice is represented by the belief that peritoneal exchanges can be safely started at least 2 weeks after catheter insertion, due to the concern of early mechanical complications. The study investigated the efficacy and safety of an UPD approach in our PD program. METHOD Between 1 January 2009 and 31 December 2019 all prevalent patients needing UPD at our institution were included in the study. During this period, 242 peritoneal catheters were inserted in 222 patients (Table 1). One hundred forty-eight catheters were positioned semi-surgically, while 94 were inserted surgically. In all patients, an anti-leakage/dislocation suture was made. PD was started within 24 h from catheter placement and peritoneal exchange scheme characterized by progressively increasing volume was used; early and late mechanical complications were also analysed. Finally, all the causes of PD technique and catheter failure were reported. RESULTS The early incidence of leakages, catheter dislocations, omental wrappings, bleeding, peritonitis and exit-site infections was 11/242 (4.5%), 5/242 (2%), 3/242 (1.2%), 2/242 (0.8%), 6/242 (2.5%) and 4/242 (1.6%), respectively (Table 2). No bowel perforations were observed. The long-term leakage rate and catheter dislocation were 0.016 and 0.019 episodes/patient-year, respectively (Table 3). The survival of the catheter at 3, 6, 12, 24, 36 and 48 months was 93.6, 91.2, 84.8, 77.4, 65.5 and 59.3%, respectively (Fig. 1). The technique survival at 3, 6, 12, 24, 36 and 48 months was 97.2, 94.9, 87.6, 78.9, 66.6 and 60.0%, respectively (Fig. 2). The main cause of PD dropout was represented by infectious complications (nearly 40%) and mechanical complications (17.5%) leading to catheter failure (Fig. 3). No significant difference in the first catheter survival among the semi-surgical and the surgical arm was observed (HR 0.88 [CI 0.54–1.45], P = 0.62 [Fig. 4]). CONCLUSION A tight seal between deep cuff and surrounding tissue (double-purse string technique) with a low-volume exchange scheme allows starting UPD soon after catheter insertion minimizing mechanical complications. In patients without previous abdominal interventions semi-surgical technique is as effective as the surgical procedure in preventing early mechanical complications.

Two-Stage Arterial Switch for Transposition of the Great Vessels in Older Children

BackgroundThis study investigated a 2-stage arterial switch operation (ASO) to treat transposition of the great arteries (TGA) with intact ventricular septum (TGA-IVS) in late referral patients. MethodsWe retrospectively analyzed patients with TGA-IVS or TGA with restricted ventricular septal defects who had undergone 2-stage ASO at our institution from February 2007 to August 2018. Included were 41 patients: 21 (51.2%) who had undergone long-term 2-stage ASO and 20 (48.8%) who had undergone rapid 2-stage ASO. ResultsThe long-term 2-stage group was older at ASO (3.5 vs 25 months; P < .001). Results were more satisfactory in the long-term group than in the rapid group for intensive care unit time (P = .004), mechanical ventilation time (P = .004), and length of stay (P = .007). No in-hospital death occurred in the long-term group, and the postoperative course was more manageable in the long-term group than in the rapid group. However, the risk of significant neoaortic regurgitation was lower in the rapid group, which also had a better left ventricular ejection fraction. ConclusionsThe long-term group achieved better early-term outcomes than the rapid group. However, a high risk of neoaortic regurgitation and myocardial dysfunction was also noted.

Urgent-Start Peritoneal Dialysis as a Bridge to Definitive Chronic Renal Replacement Therapy: Short- and Long-Term Outcomes.

Background: The peritoneal dialysis (PD) urgent-start pathway, without typical 2-week break-in period, was meant for late-referral patients able and prone to join PD-first program, with its main advantages such as: keeping the vascular system intact, preserving their residual renal function and retaining life-style flexibility. We compared the short- and long-term outcomes of consecutive 35 patients after urgent- and 94 patients after the planned start of PD as the first choice.Methods: The study included all incident end-stage renal disease patients starting PD program between January 2005 and December 2015, classified into two groups: those with urgent (unplanned) and those with elective (planned) start. Urgent PD was initiated as an overnight automatic procedure (APD) with dwell volume gradually increased, and after 2–3 weeks, target PD method was established.Results: The mean time between catheter implantation and PD start was 3.5 ± 2.3 in urgent and 16.2 ± 1.7 days in planned-start groups (p < 0.00001). 51% of the patients in the urgent-start group required PD during first 48 h after catheter insertion. Mean follow-up of 17.6 ± 11.09 months (median: 19.0) was in the urgent-start group and 28.6 ± 26.6 months (median: 19.5) in the planned-start group. The early mechanical complications were observed more often in the urgent-start group (29 vs. 4%, p = 0.00005). The only significant predictors of early mechanical complications were serum albumin (p = 0.02) and time between the catheter insertion and PD start. The first year patient survival and technique survival censored for death and kidney transplantation were not significantly different between groups. In Cox proportional analysis the independent risk factors for patient survival as well as for method and patient survival appeared Charlson Comorbidity Index CCI (HR 1.4; p = 0.01 and 1.24; p = 0.02) and time from catheter implantation to PD start with HR 5.11; p = 0.03 and 4.29; p = 0.04 for <2 days, while time >14 days lost its predictive value (p = 0.07).Conclusion: Peritoneal dialysis may be a feasible and safe alternative to HD in patients who need to start dialysis urgently without established dialysis access, with an acceptable complications rates, as well as patient and technique survival.

Induction Therapy in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis with Renal Involvement: The Nephrologist’s Point of View

Renal involvement with rapidly progressive glomerulonephritis is a common manifestation of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides characterised by end-stage renal disease and high mortality rates in untreated and late referral patients. Long-term renal survival has improved dramatically since the addition of cyclophosphamide and, more recently, rituximab in association with corticosteroids to remission induction therapeutic regimens. However, renal prognosis remains unfavourable for many patients and mortality is still significantly higher than in the general population. In this review, the open challenges to be addressed to optimise remission induction therapy, especially in patients with advanced kidney failure, are analysed. This concerns the first-line therapy (cyclophosphamide or rituximab) based on different parameters (estimated glomerular filtration rate at baseline, new or relapsed disease, ANCA specificity, tissue injury, and safety) and the role of plasma exchange. Furthermore, the paper discusses future perspectives on induction remission therapy by reporting recent advances in new targeted therapies, with particular reference to avacopan, an orally administered selective C5a receptor inhibitor.

Antineutrophil cytoplasmic antibody associated vasculitides with renal involvement: Open challenges in the remission induction therapy.

Renal involvement with rapidly progressive glomerulonephritis is a common manifestation of antineutrophil cytoplasmic antibody (ANCA) associated vasculitides, which is characterized by end-stage renal disease and high mortality rates in untreated and/or late referral patients. The long-term renal survival has improved dramatically since the addition of cyclophosphamide (CYC) and recently of rituximab (RTX) in association with corticosteroids in the remission induction therapeutic regimens. However, renal prognosis remains unfavorable for many patients and the mortality rate is still significantly high. In this review, we analyze the open challenges to be addressed to optimize the induction remission therapy, principally in patients with advanced kidney failure. This concern the first-line therapy (CYC or RTX) based on different parameters (estimated glomerular filtration rate at baseline, new or relapsed disease, ANCA specificity, tissue injury, safety), the role of plasma exchange and the role of new therapies. Indeed, we discuss future perspectives in induction remission therapy by reporting recent advances in new targeted therapies with particular reference to avacopan, an orally administered selective C5a receptor inhibitor.

Late referral for chronic kidney disease patients: nutritional point of view.

The prevalence of late referral of patients with chronic kidney disease (CKD) is high and has been associated with a worse CKD prognosis, however few studies have been conducted from a nutritional perspective. Characterize the nutritional status of patients with CKD at first attendance in a nephrology service, with early (ER) and late referral (LR). It was a cross-sectional study with patients older than 18 years referred to the Nephrology service of a University Hospital. The referral groups were classified according to estimated glomerular filtration rate (eGFR) as: LR (eGFR15 ml/min/1.73m2) based on the Kidney Disease Outcomes Quality Initiative. Nutritional evaluation included subjective global assessment (SGA), anthropometric, laboratory and bioelectrical impedance data. The SAS software was used for statistical analysis. Seventy-five patients were evaluated, 29% of them belonging to the LR group. This group showed a greater previous weight loss (-7.0 ± 3.5 versus -2.8 ± 7.0 Kg) and lower values for all anthropometric and body composition variables. In general, the laboratory results of the LR group also were worse. According to the SGA, all LR patients had some degree of malnutrition (50% with severe malnutrition against 28.8% in ER), showing significantly lower results for GFR (21.4 + 12.2 ml/ min/1.73 m2), albumin (3.9 + 0.3 g/dL), serum bicarbonate (22.8 + 5.1 mmol/L) and phase angle (5.3+ 0.6 θ). Renal function was positively correlated with percent adequacy of arm circumference (r=0,40; p<0,01) and albumin (r=0,45; p<0,01). The LR group showed a worse nutritional status showing that, for the nutritional point of view, the delayed referral brings substantial losses that can make difference in future treatment, thus demonstrating the importance of early nutritional monitoring for this population.

Early nephrology referral reduces the economic costs among patients who start renal replacement therapy: a prospective cohort study in Korea.

BackgroundThe nature of cost-saving effects of early referral to a nephrologist in patients with chronic kidney disease (CKD) is not fully evaluated. We evaluated the health care costs before and after dialysis according to the referral time.MethodsA total of 879 patients who were newly diagnosed as having end-stage renal disease from August 2008 to June 2011 were prospectively enrolled. The early referral (ER) group was defined as patients who were referred to a nephrologist more than a year before dialysis and had visited a nephrology clinic 2 or more times. Patients whose referral time was less than a year were considered the late referral (LR) group. Information about medical costs was acquired from the claim data of the Korea Health Insurance Review and Assessment Service.ResultsThe total medical costs during the first 12 months after the initiation of dialysis were not different between the 526 ER patients and the 353 LR patients. However, the costs of the ER patients during the first month were significantly lower than those of the LR patients (ER vs. LR: 3029±2219 vs. 3438±2821 US dollars [USD], P = 0.025). The total 12-month health care costs before the initiation of dialysis were significantly lower in the ER group (ER vs. LR: 6206±5873 vs. 8610±7820 USD, P<0.001). In the multivariate analysis, ER significantly lowered the health care costs during the 12 months before (2534.0±436.2 USD, P<0.001) and the first month (428.5±172.3 USD, P = 0.013) after the initiation of dialysis.ConclusionsThe ER of patients with CKD to a nephrologist is associated with decreased medical costs during the pretreatment period of renal replacement therapy and the early period of dialysis initiation.

Early referral to nephrologist is required for improving outcome of chronic kidney disease patients

Objective The aim of our study was to evaluate the impact of late referral (LR) on health parameters and mortality rate of chronic kidney disease (CKD) patients. Patients and methods This retrospective study includes patients referred to the Renal Replacement Therapy Unit. Patients were classified as early referrals (ERs) if their first encounter with a nephrologist occurred within 16 weeks before initiation of dialysis and all others patients were considered LRs. Collected data included constitutional data, data on underlying kidney diseases, clinical and laboratory data, and the modified Charlson comorbidity index (CCI). The outcomes of the study are presented as the follow-up mortality rates in both groups and their relationship with the timing of referral and collected data. Results The study included 370 CKD patients: 140 ERs and 230 LRs. Patients of the LR group had significantly higher blood pressure (BP) and CCI scores compared with those of the ER group. Laboratory data showed significantly lower hemoglobin concentration and estimated glomerular filtration rate (eGFR) with significantly higher serum phosphate, total cholesterol, and low-density lipoprotein levels in the LR group compared with the ER group. Thirty-one patients (8.4%) died: six from the ER group and 25 from the LR group, with a significantly higher mortality rate in the LR group compared with the ER group. Survival was negatively correlated with time till referral, age, CCI, BP, and multiplicity of associated comorbidities, whereas it was positively correlated with female sex and high eGFR. Statistical analyses showed that high CCI and low eGFR were significant specific predictors, whereas old age, LR, and high systolic BP were significant sensitive predictors for mortality. In the Cox regression analysis, the survival rate in ER patients was significantly better than that in LR patients after adjusting for several risk factors. Conclusion ER of CKD patients to a nephrologist significantly minimizes morbidities and improves the chances of survival, which is significantly affected by age, multiplicity of associated comorbidities, and GFR. Improving the knowledge of patients and general physicians on the hazards of LR to nephrologists will definitely improve the outcome of patients with CKD.

Different prevalence of metabolic control and chronic complication rate according to the time of referral to a diabetes care unit in the elderly

The time of diagnosis is crucial for type 2 diabetes mellitus (T2DM) in terms of disease severity and chronic complications, as initial glycated haemoglobin (HbA1c) predicts 5-year cardiovascular mortality. The Italian health-care system relies on about 650 diabetes care units (DCU) interfacing with a large number of general practitioners (GPs). It may thus reach the goal of preventing complications easier than others by adopting a more comprehensive multifactorial approach. To assess whether the interval between diagnosis and referral to the DCU might influence the course of the disease in terms of HbA1c, associated cardiovascular risk factors, drug utilisation, and chronic complications in the elderly, the electronic records of 313 elderly T2DM patients (74.6±4.9years) followed by their GPs until referral to our DCU were retrospectively analysed for the above-mentioned parameters and divided into an early referral (ER) group (diagnosed within 12months, n=111) and a late referral (LR) group (diagnosed >12months before, n=202). A further set of 200 patients routinely taken care by our DCU, matched with the LR group for age, gender, and disease duration, was classified as "long-standing follow-up" (LSF) and compared to the others to rule out any confounding effects of long-standing disease per seon the clinical outcomes investigated in our study. About 35% of T2DM patients referred to our DCU within 12months of diagnosis; the rest did so some 5years after diagnosis. LR patients displayed worse HbA1c levels (10.8 vs. 7.7%, p<0.01), used more drugs, and had more than twice as high complication rates as their ER counterparts. Almost all risk factors and complications were lower in the LSF (0.001<p<0.05) and ER groups than in the LR group. In both the ER and the LSF groups, we observed a lower burden of diabetes than in the LR group. This rules out the possibility that disease duration might play a major role per se in the burden of the disease in the elderly as opposed to the thoughtful patient care attitude exhibited by the DCU. A better and more efficient organisation has to be developed, including a strong interaction among GPs, diabetes specialists, and elderly people with T2DM allowing the latter to take charge of their own disease management through a sustained empowerment policy.

Conoscerlo per riconoscerlo: morbo di Addison con sindrome poliendocrina autoimmune di Tipo 2

Viene presentato un caso clinico di iposurrenalismo da morbo di Addison primitivo sviluppatosi dopo alcuni anni dalla comparsa di un morbo di Graves. Tale combinazione rappresenta una poliendocrinopatia autoimmune di tipo 2 (SPA-2). La SPA-2 è un processo autoimmune che coinvolge più tessuti endocrini (surrene, tiroide, pancreas) e non endocrini. Si ritiene che la sindrome si sviluppi in pazienti geneticamente predisposti con diversi pattern genetici del complesso maggiore di istocompatibilità MHC II. La SPA-2 è una malattia rara, avendo una frequenza di una persona affetta ogni 7000–8000 abitanti, prevale nel sesso femminile e compare a un'età media di circa 35 anni. L'iposurrena-lismo è caratterizzato da sintomi tipici (astenia, ipotensione ortostatica, calo ponderale, artromialgie, nausea, anoressia, iperpigmentazione cutanea), tuttavia non facili da interpretare, data la scarsa conoscenza della malattia. Nei casi non diagnosticati in tempo utile i sintomi possono peggiorare in rapporto a eventi stressanti che possono far precipitare i pazienti in una crisi addisoniana che può essere potenzialmente fatale. Iposodiemia, iperpotassiemia, iperazotemia, ipercalcemia associati ad aumentati livelli plasmatici di ACTH, renina, e bassi livelli di cortisolo, e alterati indici di epatolisi sono riscontri laboratoristici relativamente tardivi, così come possono esserlo i segni clinici di disidratazione. La storia naturale della malattia si manifesta attraverso varie fasi progressive: a) dapprima con presenza di autoanticorpi anti-surrene presenti anni prima all'esordio clinico, b) poi con un aumento della renina plasmatica e con la diminuzione dell'aldosterone plasmatico, c) poi con la successiva ridotta risposta del cortisolo allo stimolo con ACTH e.v. e d) infine con iperincrezione di ACTH, calo del cortisolo basale e presenza delle manifestazioni cliniche di iposurrenalismo. Il trattamento si basa sulla sostituzione ormonale degli organi endocrini coinvolti.

Early Referral to a Nephrologist Improved Patient Survival: Prospective Cohort Study for End-Stage Renal Disease in Korea

The timing of referral to a nephrologist may influence the outcome of chronic kidney disease patients, but its impact has not been evaluated thoroughly. The results of a recent study showing an association between early referral and patient survival are still being debated. A total of 1028 patients newly diagnosed as end-stage renal disease (ESRD) from July 2008 to October 2011 were enrolled. Early referral (ER) was defined as patients meeting with a nephrologist more than a year before dialysis and dialysis education were provided, and all others were considered late referral (LR). The relationship of referral pattern with mortality in ESRD patients was explored using a Cox proportional hazards regression models. Time from referral to dialysis was significantly longer in 599 ER patients than in 429 LR patients (62.3±58.9 versus 2.9±3.4 months, P<0.001). Emergency HD using a temporary vascular catheter was required in 485 (47.2%) out of all patients and in 262 (43.7%) of ER compared with 223 (52.0%) of LR (P = 0.009). After 2 years of follow-up, the survival rate in ER was better than that in LR (hazard ratio [HR] 2.38, 95% confidence interval [CI] 1.27–4.45, P = 0.007). In patients with diabetes nephropathy, patient survival was also significantly higher in ER than in LR (HR 4.74, 95% CI 1.73–13.00, P = 0.002). With increasing age, HR also increased. Timely referral to a nephrologist in the predialytic stage is associated with reduced mortality.

Knowing it for detecting it: Addison disease with type 2 autoimmune polyendocrine syndrome

Here we describe a patient who developed autoimmune hypoadrenalism many years after developing Graves’ disease. This combination depicts an autoimmune polyendocrine syndrome type-2 (APS-2). APS-2 is an autoimmune syndrome involving endocrine (adrenal glands + thyroid, and/or type 1 diabetes mellitus) and non-endocrine autoimmune disorders. APS-2 has a genetic background showing an association with the class II major histocompatibility complex. APS-2 is an uncommon disease (1:8,000 inhabitants) with higher prevalence in females and mean onset age of 35 years. Despite the fact that hypoadrenalism is characterized by specific symptoms and signs (asthenia, fatigue, orthostatic hypotension, weight loss, nausea, arthralgia, anorexia, skin hyperpigmentation) it is not easy to diagnose at early stages. In late referral patients clinical symptoms can worsen, due to stress events, until a possibly fatal addisonian crisis. Hyponatremia, hyperkalemia, increased levels of ACTH, renin, and low levels of Cortisol, hepatic failure as well as clinical signs and symptoms of dehydration are late laboratory findings. The natural history of the disease develops in different, progressive phases: (i) presence of adrenal cortex autoantibodies many years before the first clinical manifestations, (ii) initial increased levels of plasmatic renin and low levels of aldosterone, (iii) followed by a reduced response of Cortisol to the intravenous ACTH stimulation, (iv) and finally increased levels of plasmatic ACTH and low levels of Cortisol and clinical manifestations of adrenal insufficiency. The therapy of APS-2 is mainly focused on hormone therapy of the affected glands.

Causes and outcome of late referral of children who develop end‐stage kidney disease

This study aims to characterise the timing of referral to a paediatric nephrology unit of children who develop end-stage kidney disease (ESKD). This study also aims to determine whether late referral (LR) influences outcomes and to explore factors that may lead to LR. A retrospective case review of all incident patients with ESKD who received renal replacement therapy (RRT) at a single paediatric centre. Time between referral to a paediatric nephrologist and commencement of RRT, demographic and clinical data were collated. Estimated glomerular filtration rate (eGFR) at referral was calculated using height and creatinine. LR was defined as having an eGFR ≤ 30 mL/min/1.73 m(2) when first seen by a paediatric nephrologist. RRT was initiated for 74 patients < 18 years of age between 1988 and 2010. The median age at referral was 2.0 years (birth-15.9 years) and age at RRT was 10.0 years (6 days-17.4 years). Children referred before age 1 year (41%) had a more prolonged course before ESKD. Median (interquartile range) eGFR at referral of children > 1 year was 27.2 (9.0-52.0) mL/min/1.73 m(2) . Twenty-two (55%) of these children were referred late (LR) with an eGFR ≤ 30 mL/min/1.73 m(2) . LR patients were more likely to have glomerulonephritis or haemolytic uraemic syndrome and to live in a remote or outer regional area. LR patients had higher urea, lower haemoglobin and were more likely to receive haemodialysis via a vascular catheter. A significant proportion of children who develop ESKD are referred late to nephrology units with potentially preventable complications. Aetiology of renal disease and geographic isolation contribute to LR.

Un plaidoyer pour la dialyse péritonéale

The prevalence of peritoneal dialysis in France remains one of the lowest in Europe in spite of official recommendations in 2008. Progress in peritoneal catheter placement and a good knowledge of the management of catheter complications are essential. A more frequent use of biocompatible solutions should achieve a better preservation of the peritoneal membrane. Such physiological peritoneal fluids seem to decrease morbidity and mortality. Best peritoneal dialysis indications are mainly young patients waiting for a kidney transplantation, old patients without malnutrition and patients with cardiac insufficiency. Objective and complete information dedicated to both peritoneal dialysis and hemodialysis is necessary, even for patients seen in emergency or unplanned or late referral patients. A pre-end-stage renal disease education program has to be mandatory. Non-medical obstacles, mainly financial, are still common so that economic incitations are necessary for the development of peritoneal dialysis. A university formation of nephrologists is now available.

How does late nephrological co-management impact chronic kidney disease? - An observational study

To assess the impact of late referral (LR) for nephrological co-management compared with early referral (ER) on morbidity and mortality in chronic kidney disease (CKD) and to identify individual factors associated with higher mortality in LR, correcting for lead-time and immortal time bias. Retrospective observational study comparing 46 LR patients with 103 ER patients. The quality of CKD management was assessed by measures to prevent CKD progression and to modify CKD complications and cardiovascular risk factors according to current guidelines. One-year mortality of LR and ER was compared and factors associated with mortality were identified. Analysis was performed with equivalent GFR (glomerular filtration rate) of ER and LR at baseline to correct for lead-time and immortal time bias. Late referral was associated with inferior control of most risk factors for CKD progression, CKD complications and cardiovascular risk factors. In particular, glycaemic control, the use of angiotensin converting enzyme inhibitors and angiotensin-2-receptor blockers in diabetic nephropathy or proteinuria, the control of nutritional and volume status were inferior in LR. One-year mortality was significantly higher in LR (RR 5.9 (95% CI 1.5-19.6); p < 0.01). Inadequate control of blood pressure, anaemia, volume status, malnutrition and emergency initial dialysis, but not LR itself were independently associated with mortality. Late referral was associated with a substantially lower survival after correction for lead-time and immortal time bias and with inferior control of most risk factors for CKD progression, complications and cardiovascular risk factors. CKD patients may particularly profit from adequate control of blood pressure, anaemia, nutritional and volume status, and avoidance of emergency initial dialysis as these factors may predominately contribute to survival.

Catheter access for hemodialysis defines higher mortality in late-presenting dialysis patients

Background: This study explores the relationship between mortality and late presentation for dialysis, focusing on the role of catheter access for hemodialysis (HD). Methods: We analyzed data from a cohort of 286 patients commencing dialysis in 2000–2001. Survival and factors associated with death were analyzed by univariate and multivariate analysis. Dialysis access was considered in three groups: HD-AVF, HD-Catheter, and peritoneal dialysis (PD). Late referral (LR) was defined as first review by a nephrologist less than 90 days before dialysis. Results: One-year mortality was low at 10.1%. HD-Catheter patients were older (p < 0.001), more hypoalbuminemic (p < 0.001), more anemic (p = 0.005), and more likely to be LR (p < 0.001). HD-Catheter patients did not have significantly higher comorbidity (p = 0.128). HD-Catheter was strongly associated with late presentation (75% LR vs. 28% early referral, p < 0.001). Factors associated with death by univariate analysis included age (p < 0.0001), comorbidity (p < 0.0001), HD-Catheter (p < 0.0001), LR (p = 0.0001), hypoalbuminemia (p = 0.0011), and diabetes (p = 0.02). When corrected for these factors, HD-Catheter was associated with death (HR 2.226, 95% CI 1.314–3.772, p = 0.003) but LR was not (p = 0.38). Conclusions: A predominant feature of LR that predicts mortality is the use of catheter access for HD. This may be modifiable in those LR patients who do not present as uremic emergencies.

Early Nephrology Referral Is Associated With Prolonged Survival in Hemodialysis Patients Even After Exclusion of Lead-Time Bias

BackgroundEarly nephrology referral (ER) has been suggested to lower morbidity and mortality in dialysis patients, but the nature of the association has been criticized as possibly because of lead-time bias. This study aims to evaluate if ER is associated with improved survival of hemodialysis patients when the lead-time bias is excluded. MethodsA total of 192 hemodialysis patients from a medical center and a regional hospital were enrolled in the period from January 1997 to December 2006. ER and late referral (LR) were defined as referral to nephrologists greater or less than 6months, respectively, before the initiation of hemodialysis. Follow-up of clinical course in all patients was timed from the date at which estimate glomerular filtration rate was estimated to be 15mL/min/1.73m2. The relative overall survival was analyzed by Cox-regression adjusted for their demographic and comorbid conditions ResultsCompared with LR patients, ER patients were less likely to have hypoalbuminemia in the beginning of hemodialysis, more likely to have received erythropoietin or phosphate binder therapy, more likely to have a vascular access created before the first hemodialysis, and had a slower rate of renal function decline before hemodialysis. In multivariate analysis, LR (hazard ratio: 2.827; P=0.049) and diabetes mellitus were both independently associated with increased mortality risk. The survival benefits of ER seem to be originated from the period before initiation of renal replacement therapy. ConclusionsOur findings show that ER is significantly associated with prolonged survival after exclusion of lead-time bias, which is consistent with ER being associated with better clinical outcomes in hemodialysis patients.

Late Referral to a Nephrologist Increases the Risk of Uremia-Related Cardiac Hypertrophy in Patients on Hemodialysis

Background: The prognosis and outcome of patients with end-stage renal disease are related to the quality of predialysis care and the timing of referral. Late referral (LR) has been correlated with more frequent hospital admissions, malnutrition and cardiovascular mortality after hemodilaysis (HD) is started. Methods: We investigated the effects of LR on cardiac hypertrophy, uremia-related metabolic risk factors and mortality in patients on HD. A baseline echocardiography was performed in 119 patients on HD, 67 of whom were early referrals (ER, referred more than 3 months before the start of HD) and 52 were LR (referred less than 3 months before the start of HD; median (range): 22.5 (4–120) vs. 1.0 (0–3) months, respectively). Results: The survival curves showed a higher mortality rate in the LR patients than in the ER patients (log rank, p = 0.004). More patients in the LR group died of cardiovascular disease compared to the ER patients (p = 0.04). The plasma levels of albumin were significantly lower (p < 0.05), and the intact parathyroid hormone (iPTH) and log C-reactive protein (log CRP) were significantly higher in the LR patients compared to the ER patients (p < 0.05 and p < 0.001, respectively). The LR patients, especially nonsurvivors, showed greater impairment of systolic cardiac function and more concentric left ventricular hypertrophy (LVH) than ER patients, as determined by interventricular septal thickness (p < 0.001), left ventricular posterior wall thickness (p < 0.001), relative wall thickness (p = 0.02), and the left ventricular mass index (LVMi, p < 0.001). Interestingly, the duration of the pre-HD treatment, after referral, was positively associated with the plasma albumin (r = 0.229; p = 0.01) and negatively associated with the log CRP (r = –0.350; p < 0.001), iPTH (r = –0.309; p = 0.001) and LVMi (r = –0.268; p = 0.004). Multiple linear regression analysis also demonstrated that the log CRP and iPTH as well as the LR were independently associated with LVMi in the HD patients (p < 0.05). Conclusions: The results of this study demonstrated that the LR HD patients were at an increased risk for more cardiovascular related mortality, severe concentric LVH and systolic dysfunction accompanied by inflammatory and malnutrition indices, as well as with increased iPTH levels. In the LR patients, the more severe LVH associated with severe inflammatory indices, as well as the higher iPTH levels, may be one of the causes of LR-related mortality.

Ultralate Referral and Presentation for Renal Replacement Therapy: Socioeconomic Implications

Clinical and metabolic complications of late referral (LR) for dialysis therapy have been well documented, but there is a paucity of data on its socioeconomic implications. This study examines the role of lifestyle and socioeconomic status on referral pattern. During a 4-year period (1999 to 2002), we retrospectively reviewed records of all patients who initiated dialysis therapy at an urban tertiary-care center. Patients were classified into 3 categories according to the interval between first contact with a nephrologist and initiation of dialysis therapy: contact time of 3 months or longer indicates early referral (ER); 1 to less than 3 months, LR; and less than 1 month, ultralate referral (ULR). Of 460 patients (97% African Americans, 3% Hispanics), 212 patients (46%) were ULR, 168 patients (37%) were LR, and 80 patients (17%) were ER. Compared with ER and LR patients, those with ULR had significantly (P < 0.0001) lower hematocrits (23% versus 29% and 27%), serum albumin levels (3.1 versus 3.3 and 3.2 g/dL [31 versus 33 and 32 g/L]), and glomerular filtration rates (5 versus 8 and 7 mL/min/1.73 m2 [0.08 versus 0.13 and 0.12 mL/s/1.73 m2]), but greater rates of temporary dialysis catheter use (92% versus 39% and 70%) and mortality (40% versus 15% and 26%, respectively). Logistic regression analysis showed an association between mortality and homelessness (odds ratio, 3.8; P < 0.0001), polysubstance abuse (odds ratio, 2.3; P = 0.013), and alcoholism (odds ratio, 2.2; P = 0.009). Alcoholics (odds ratio, 2.5; P = 0.03), substance abusers (odds ratio, 5.5; P = 0.001), and the homeless/unemployed (odds ratio, 6.0; P = 0.004) were more likely to present as ULR cases. Patient-provided explanations for LR and ULR were denial (45%), unawareness of the presence of chronic kidney disease (30%), and economic difficulties (25%). Denial was more prevalent in LR (52%; P = 0.003) and ULR cases (39%; P = 0.003). Poor socioeconomic status is a major contributor to delayed referral. More efforts need to be directed at patient and physician chronic kidney disease educational awareness and improved health care access for inner-city and minority populations.