Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States

Background: Recent studies have suggested that early predialysis nephrological care is associated with lower mortality; however, this hypothesis has not been tested in a population-based study. We evaluated the impact of early nephrology referral and pre-end-stage renal disease (ESRD) care on mortality risk in a national cohort of new patients starting dialysis therapy in 1996 and 1997. Methods: Data were obtained on a subset of patients (n = 2,264; 56%) from the Dialysis Morbidity and Mortality Study Wave 2 who then were followed up for up to 2 years. Survival comparisons were made using log-rank test, then by Cox regression adjusting for demographics, comorbid medical conditions, and surrogate markers of pre-ESRD care. Results: Adjusted mortality risks (relative risks [RRs]) were higher for late- (within 4 months of dialysis initiation) compared with early-referred patients at the end of 1 and 2 years of follow-up (RR, 1.68; confidence interval [CI], 1.31 to 2.15; RR, 1.23; CI, 1.02 to 1.47, respectively). Mortality risks were similarly high for the late-referred nondiabetic (RR, 2.10; CI, 1.49 to 2.94) and hemodialysis subgroups (RR, 1.72; CI, 1.25 to 2.38). Conversely, mortality risks were lower for patients who saw a nephrologist at least twice in the year before dialysis therapy initiation (RR, 0.80; CI, 0.62 to 1.03; P = 0.08] compared with those who did not. Conclusion: Late nephrology referral is associated with greater death risk in new patients with ESRD, and more frequent pre-ESRD care confers increased survival benefit. These findings stress the need for earlier referral of patients to nephrologists and improved pre-ESRD care for all patients approaching ESRD in the United States to improve survival. Am J Kidney Dis 41:310-318. (C) 2003 by the National Kidney Foundation, Inc.