Late referral to maintenance dialysis: detrimental consequences

Thirty per cent of patients who started maintenance haemodialysisat our institution between January 1989 and December 1991 hadbeen referred at a very late stage of their renal disease. Toassess the causes and consequences of such late referral weretrospectively compared clinical and laboratory features of65 patients who had been referred less than 1 month prior tofirst dialysis (late referral, or LR group) and of 153 patientswho had been previously followed-up by us for more than 6 months(early referral, or ER group). Age, sex ratio, and socioeconomicstatus were similar in the two groups. In the LR group, 38 patientshad never been referred to a nephrology unit, whereas 27 haddiscontinued nephrological surveillance. Fluid overload, severehypertension, and/or pulmonary oedema was present in 57% ofLR versus 15% of ER patients (P<0.001). Mean (±1 SD)systolic and diastolic blood pressure was greater in the LRthan the ER group (173 ± 19/99±12 versus 147±15/84±8mmHg, 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 theER group. Most (88%) LR patients started dialysis in emergencyconditions through central vein Catheterization. Total hospitalstay lasted 34.5±16.3 days in LR versus 5.8±3.0days in ER patients (P<0.0001), resulting in an excess costof 0.2 million French francs per LR patient. We conclude thatpatients referred at a late stage of renal failure without previousnephrological follow-up had strikingly more severe uraemic disorders,together with poorer blood pressure control and clinical condition,than patients receiving adequate nephrological care, and neededprolonged hospitalization to recover. Such potentially avoidabledeleterious effects strongly suggest the need for earlier andcloser co-operation between general practitioners and nephrologists.