Delayed referral to a nephrologist: outcomes among patients who survive at least one year on dialysis

Objective: To investigate whether late referral to a nephrologist of patients with chronic renal insufficiency influences the likelihood of both transplantation and mortality among those who survive at least one year on dialysis. Design: Retrospective national cohort study, using data from the Australia and New Zealand Dialysis and Transplant Registry database. Participants: All patients with end-stage renal disease who started renal replacement treatment in Australia between 1 April 1995 and 31 December 1998, excluding those who received transplants or who died in their first year of dialysis. Patients referred "late" were defined as those who needed to commence dialysis within three, months of referral to a nephrologist. Main outcome measures: Length of patient survival, and whether patients received a transplant at any time between one year after starting dialysis and completion of the study on 31 March 2000. Results: Of the 4243 patients included in the study, 1141 (26.9%) were referred late. Late-referral (LR) patients were significantly less likely to receive a transplant in their second and subsequent years on dialysis (adjusted rate ratio, 0.78; 95% Cl, 0.64-0.95). LR patients were at significantly increased risk of death after their first year on dialysis (adjusted hazard ratio, 1.19; 95% Cl, 1.04-1.35). Conclusions: Late referral is associated with increased mortality, even among those who survive their first year on dialysis. Improving the quality of pre-dialysis care might improve access to transplantation and long-term survival. General practitioners could minimise late referrals through targeted screening of high-risk individuals.