Nephrol Dial Transplant (1993) 8: 1089-1093
© 1993 European Renal Association-European Dialysis and Transplant Association
research-article
Late referral to maintenance dialysis: detrimental consequences
Department of Nephrology and INSERM U90 Necker Hospital, Paris, France
Correspondence and offprint requests to: Correspondence and offprint requests to: Dr Paul Jungers MD, Département de Néphrologie, Hôpital Necker, 149 rue de Sèvres, 75015 Paris, France
Thirty per cent of patients who started maintenance haemodialysis at our institution between January 1989 and December 1991 had been referred at a very late stage of their renal disease. To assess the causes and consequences of such late referral we retrospectively compared clinical and laboratory features of 65 patients who had been referred less than 1 month prior to first dialysis (late referral, or LR group) and of 153 patients who had been previously followed-up by us for more than 6 months (early referral, or ER group). Age, sex ratio, and socioeconomic status were similar in the two groups. In the LR group, 38 patients had never been referred to a nephrology unit, whereas 27 had discontinued nephrological surveillance. Fluid overload, severe hypertension, and/or pulmonary oedema was present in 57% of LR versus 15% of ER patients (P<0.001). Mean (±1 SD) systolic and diastolic blood pressure was greater in the LR than the ER group (173 ± 19/99±12 versus 147±15/84±8 mmHg, P<0.001). Mean plasma concentration of creatinine, urea and phosphate was significantly greater, whereas bicarbonate, calcium, haematocrit and albumin were less in the LR than the ER group. Most (88%) LR patients started dialysis in emergency conditions through central vein Catheterization. Total hospital stay lasted 34.5±16.3 days in LR versus 5.8±3.0 days in ER patients (P<0.0001), resulting in an excess cost of 0.2 million French francs per LR patient. We conclude that patients referred at a late stage of renal failure without previous nephrological follow-up had strikingly more severe uraemic disorders, together with poorer blood pressure control and clinical condition, than patients receiving adequate nephrological care, and needed prolonged hospitalization to recover. Such potentially avoidable deleterious effects strongly suggest the need for earlier and closer co-operation between general practitioners and nephrologists.
Keywords: renal replacement therapy; nephrological follow-up; maintenance haemodialysis; morbidity; late referral
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|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
 |
|
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|
|
|
|
|
|
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|
|
|
|
|
|
R. Walker Recent advances :General management of end stage renal disease BMJ, November 29, 1997; 315(7120): 1429 - 1432. [Full Text]
|
|