Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients

Background. Late nephrological referral or chronic renal failure patients has been shown to be associated with high morbidity and short-term mortality on dialysis. However. the impact of predialysis nephrological care duration (PNCD) on the long-term survival of dialysis patients had not been evaluated. Methods. We studied data from all 1057 consecutive patients who started dialysis treatment at the Necker Hospital from 1989 to 1998 (mean age at start of dialysis 53.8 +/- 17.2 years (range 18-91 years), excluding from analysis patients who presented with acute renal failure (n = 60) or advanced malignancy (n = 35). We evaluated the effects of PNCD and clinical risk factors on all-cause mortality after long-term follow-up on dialysis. Results. Among the 1057 patients analysed (13.2%, diabetics), PNCD was < 6 months in 258 patients, 6-35 months in 267 patients, 36-71 months in 227 patients and 72 months in 307 patients. Cardiovascular (CV) morbidity, namely a history of myocardial or cerebral infarction, peripheral arteriopathy, and/or cardiac failure, before starting dialysis was 39.6% and 37.4%, respectively, in patients followed for <6 months or 6-35 months, compared with 24.4% in those followed for 36-71 months and 19.9% in those followed for 72 months (P < 0.001). Five-year survival was significantly lower in patients with a PNCD of < 6 months (59 +/- 4.1%) than for 36-71 months or greater than or equal to 72 months (77.1 +/- 3.7 and 73.3 +/- 3.6%, respectively, P<0.001), but similar to those followed for 6-35 months (65.3 +/- 3.9% NS). By Cox proportional hazard analysis, PNCD <6 months., age, diabetes and prior CV disease were independent predictive factors of all-cause death on dialysis. Conclusions. This study provides suggestive evidence that longer duration of regular nephrological care in the predialysis period. at least for several years prior to the start of dialysis. is associated with a better long-term survival on dialysis. Such data strongly support the argument for early referral and regular nephrological care of chronic renal failure patients.