Late referral for end-stage renal disease: a region-wide survey in the south west of England

Background. The proportion of patients referred for renal replacement therapy (RRT) at a late stage of disease appears to be similar to that first described nearly 20 years ago. This study investigated the Current scale of the problem in a large region in England, identifying the prior health care. patient characteristics. referral pattern, and outcomes of those accepted onto RRT. Methods. Three hundred and sixty-one (88%) out of 411 patients accepted for RRT in six renal units in the South and West Re-ion of the UK between I June 1996 and 31 May 1997 were Studied retrospectively. We examined the history of chronic renal failure, referral path to nephrologist, management of chronic renal failure (CRIF) and patient outcomes. Patients were categorized as 'late if they ere referred to the renal unit either within 4 months or within I month of requiring RRT. Results. One hundred and twenty-four (35%) patients were referred within 4 months of RRT, and 84 (23%) within 1 month. The main differences between patients referred later and other patients was seen for those referred within 1 month. These patients were older and had more co-morbidity, significantly worse laboratory parameters at the start of RRT, were less likely to have received standard treatments for CRF, had less permanent dialysis access in place at the start of RRT (18% vs 47%, P = 0.001). and had a significantly Ionizer hospital stay (18 vs 10 days, P = 0.001). Seventy-four (19%) patients died in the first 6 months: 27 (32%) in the 1-month group, 46 (16%) in all others (P = 0.002). We found no evidence that patients referred late had defaulted from nephrology follow-up or had an excess of rapidly progressive disease. Though data were incomplete, there as evidence of' prior CRF of over 1 year in all late referral group. Conclusion. Nearly a quarter of patients are referred for specialist nephology treatment at a very late stage, within 1 month of' RRT. They are less likely to receive interventions that could after the progression of CRF Or reduce its associatcd co-morbidity, have a worse clinical state at the start of RRT. longer hospitalization and poorer survival. These differences were much less marked for those referred within 1 4 months of starting RRT. although this is in insufficient time to prepare For RRT. Further research is needed to determine the missed opportunities for more proactive diagnosis and management of CRF.