Determinants of delayed nephrologist referral in patients with chronic kidney disease

doi:10.1053/ajkd.2001.29207

American Journal of Kidney Diseases

Volume 38, Issue 6, December 2001, Pages 1178-1184

https://doi.org/10.1053/ajkd.2001.29207 Get rights and content

Abstract

Late referral to nephrologists of patients with chronic kidney disease (CKD) is a major public health problem because it is prevalent and associated with increased morbidity, mortality, and greater healthcare costs. To identify factors associated with delayed nephrologist referral (first nephrologist visit < 90 days before the onset of renal replacement therapy), we identified a cohort of patients with preexisting CKD that progressed to end-stage renal failure. We developed a logistic regression model to measure the association of specific demographic and clinical covariates with delayed nephrologist referral. Delayed referral was highly associated with older age (P < 0.001), race other than white or black (P = 0.002), and the absence of certain comorbidities: hypertension (P < 0.001), coronary artery disease (P < 0.001), malignancy (P = 0.005), and diabetes (P = 0.02). Associations of late referral with male sex (P = 0.07) and lower socioeconomic status (P = 0.09) were of borderline significance. Patients who were predominantly cared for by a general internist were more likely to be referred late to a nephrologist compared with those cared for by a family or primary care practitioner (P = 0.002) or another subspecialist (P = 0.019). These findings suggest that several factors increase the risk that patients with CKD will have the first nephrologist consultation excessively late in the course of their disease. Although timely access to nephrologist services is important for all patients with advanced CKD, this is of particular concern in older patients, those in certain minority populations, and those in whom the absence of comorbidity may provide a false sense of true risk status. © 2001 by the National Kidney Foundation, Inc.

Section snippets

Patients

We identified all adult patients who began RRT from 1990 through mid-1996 who had been active participants in either the Medicare or Medicaid programs of the state of New Jersey for at least 12 months before the initiation of renal dialysis. These patients were identified using the International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes for hemodialysis, PD, other dialysis, renal transplantation, and other ESRD services. We studied all patients aged 18

Population and patient characteristics

We identified 17,884 patients who underwent first RRT at some point during 1991 to 1996 (Fig 1).

. Flow chart of the population selection process.

This cohort also included all patients who underwent one-time or short-term RRT as a consequence of acute renal failure. Of these patients, 12,557 had adequate baseline data for a full year before dialysis in Medicaid and/or Medicare to permit further study. In this population, 5,242 patients had their first renal diagnosis at least 1 year before

Discussion

We found that patients older than 74 years were much less likely to be referred to a nephrologist in a timely fashion. This confirms the earlier findings of Ifudu et al¹⁹ that patients older than 55 years were five times more likely to be referred late compared with patients aged ≤55 years. Khan et al²⁰ found a similar result for patients older than 80 years in a cohort of patients in the United Kingdom, as did Eadington et al.²¹ It is possible that nonnephrologists underestimate the value of

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Cited by (107)

Nutritional status and the risk of malnutrition in older adults with chronic kidney disease – implications for low protein intake and nutritional care: A critical review endorsed by ERN-ERA and ESPEN
2023, Clinical Nutrition
Increased life expectancy is posing unprecedented challenges to healthcare systems worldwide. These include a sharp increase in the prevalence of chronic kidney disease (CKD) and of impaired nutritional status with malnutrition-protein-energy wasting (PEW) that portends worse clinical outcomes, including reduced survival. In older adults with CKD, a nutritional dilemma occurs when indications from geriatric nutritional guidelines to maintain the protein intake above 1.0 g/kg/day to prevent malnutrition need to be adapted to the indications from nephrology guidelines, to reduce protein intake in order to prevent or slow CKD progression and improve metabolic abnormalities. To address these issues, the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Renal Nutrition group of the European Renal Association (ERN-ERA) have prepared this conjoint critical review paper, whose objective is to summarize key concepts related to prevention and treatment of both CKD progression and impaired nutritional status using dietary approaches, and to provide guidance on how to define optimal protein and energy intake in older adults with differing severity of CKD. Overall, the authors support careful assessment to identify the most urgent clinical challenge and the consequent treatment priority. The presence of malnutrition-protein-energy wasting (PEW) suggests the need to avoid or postpone protein restriction, particularly in the presence of stable kidney function and considering the patient’s preferences and quality of life. CKD progression and advanced CKD stage support prioritization of protein restriction in the presence of a good nutritional status. Individual risk-benefit assessment and appropriate nutritional monitoring should guide the decision-making process. Higher awareness of the challenges of nutritional care in older adult patients with CKD is needed to improve care and outcomes. Research is advocated to support evidence-based recommendations, which we still lack for this increasingly large patient subgroup.
Modest rates and wide variation in timely access to repeat kidney transplantation in the United States
2020, American Journal of Transplantation
Success of transplantation is not limited to initial receipt of a donor organ. Many kidney transplant recipients experience graft loss following initial transplantation and the benefits of expedited placement on the waiting list and retransplantation extend to this population. Factors associated with access to repeat transplantation may be unique given experience with the transplant process and prior viability as a candidate. We examined the incidence, risk factors, secular changes, and center-level variation of preemptive relisting or transplantation (PRLT) for kidney transplant recipients in the United States with graft failure (not due to death) using Scientific Registry of Transplant Recipients data from 2007 to 2018 (n = 39 557). Overall incidence of PRLT was 15% and rates of relisting declined over time. Significantly lower PRLT was evident among patients who were African American and Hispanic, males, older, obese, publicly insured, had lower educational attainment, were diabetic, had longer dialysis time prior to initial transplant, shorter graft survival, longer distance to transplant center, and resided in distressed communities. There was significant variation in PRLT by center, median = 13%, 10th percentile = 6%, 90th percentile = 24%. Cumulatively, results indicate that despite prior access to transplantation, incidence of PRLT is modest with pronounced clinical, social, and center-level sources of variation suggesting opportunities to improve preemptive care among patients with failing grafts.
Race and Mortality in CKD and Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study
2020, American Journal of Kidney Diseases
Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy.
Retrospective cohort study.
3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment.
Race.
Mortality.
Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC.
During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28).
Residual confounding.
The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.
Residential Area Life Expectancy: Association With Outcomes and Processes of Care for Patients With ESRD in the United States
2018, American Journal of Kidney Diseases
Citation Excerpt :
Finally, we merged data with the 2013 National Center for Health Statistics to obtain the Urban-Rural Classification Scheme (categorized on a scale of 1-6 from most urban to rural) for counties based on the Office of Management and Budget.23 We evaluated several primary processes of care and outcomes for incident patients with ESRD.24,25 Processes of care of interest were derived from the Medicare 2728 form and included the following fields: “Has the patient been informed of kidney transplant options?,”
The effects of underlying noncodified risks are unclear on the prognosis of patients with end-stage renal disease (ESRD). We aimed to evaluate the association of residential area life expectancy with outcomes and processes of care for patients with ESRD in the United States.
Retrospective cohort study.
Adult patients with incident ESRD between 2006 and 2013 recorded in the US Renal Data System (n = 606,046).
The primary exposure was life expectancy in the patient’s residential county estimated by the Institute for Health Metrics and Evaluation.
Death, placement on the kidney transplant wait list, living and deceased donor kidney transplantation, and posttransplantation graft loss.
Median life expectancies of patients’ residences were 75.6 (males) and 80.4 years (females). Compared to the highest life expectancy quintile and adjusted for demographic factors, disease cause, and multiple comorbid conditions, the lowest quintile had adjusted HRs for mortality of 1.20 (95% CI, 1.18-1.22); placement onto the waiting list, 0.68 (95% CI, 0.67-0.70); living donor transplantation, 0.53 (95% CI, 0.51-0.56); posttransplantation graft loss, 1.35 (95% CI, 1.27-1.43); and posttransplantation mortality, 1.29 (95% CI, 1.19-1.39). Patients living in areas with lower life expectancy were less likely to be informed about transplantation, be under the care of a nephrologist, or receive an arteriovenous fistula as the initial dialysis access. Results remained consistent with additional adjustment for zip code–level median income, population size, and urban-rural locality.
Potential residual confounding and attribution of effects to individuals based on residential area–level data.
Residential area life expectancy, a proxy for socioeconomic, environmental, genetic, and behavioral factors, was independently associated with mortality and process-of-care measures for patients with ESRD. These results emphasize the underlying effect on health outcomes of the environment in which patients live, independent of patient-level factors. These findings may have implications for provider assessments
Chronic kidney disease referral practices among non-nephrology specialists: A single-centre experience
2016, European Journal of Internal Medicine
Citation Excerpt :
Females were concordantly less likely to be referred to a nephrologist in another study performed by Navaneethan et al., a finding which persisted even in the geriatric population (over 65 years) [9]. Winkelmayer WC et al. found no significant gender difference [10]. In contrast, Campbell et al. concluded that female gender was a factor which significantly increased the probability of referral [11].
Early referral of CKD patients to nephrology teams (NT) is vital to identify patients most likely to progress, delay decline of excretory function, and provide planned RRT. Unfortunately, many are still being referred late.
We conducted a retrospective analysis to investigate referral rates, predictors of non-referral, and performed urine investigations in hospitalised CKD patients.
Out of 388 patients studied, 5.6%, 11.4%, and 16.4% in CKD3A, 3B, and 4 + 5, respectively, were referred to an NT upon discharge (CKD3A vs. CKD4 + 5, p = 0.016). For every additional year of age, the odds of being referred decreased by 5% (OR: 0.95, CI: 0.92–0.98, p = 0.003). Patients were more likely to be referred to an NT if they were males (OR: 2.31, CI: 1.09–4.90, p = 0.029) and having reached CKD 4 + 5 (OR: 3.99, CI: 1.58–10.10, p = 0.003). Only 28.8%, 43.9%, and 50.7% of patients with CKD3A, 3B, and 4 + 5 were followed up with urine investigations after discharge (p = 0.001). CKD stage 3B (OR: 3.54, CI: 1.23–10.19, p = 0.019), CKD stage 4 + 5 (OR: 6.06, CI: 1.69–21.67, p = 0.006), DM (OR: 6.28, CI: 2.38–16.58, p < 0.0001), and having been referred to a NT (OR: 20.95, CI: 3.54–123.92, p = 0.001) were independent predictors for having urine investigations.
The highest rate of referral was achieved in males, younger age group, and those who have reached CKD stage 4 + 5. Urine tests remain largely underutilised and only a minority (16.4%) of patients with an eGFR < 30 mL/min/1.73 m² were referred to a NT.
Analysis of emergency Department Frequentation among patients with advanced CKD (chronic kidney disease): Lessons to optimize scheduled renal replacement therapy initiation
2018, Nefrologia
Citation Excerpt :
The KDIGO Guidelines6 emphasize the initiation of RRT in symptomatic patients and/or in the presence of a glomerular filtration rate (GFR) of 5–10 mL/min. In general, these situations result from late referral to the nephrologist.2,7–9 But this will not be our scenario; now will concentrate in patients being followed in of advanced chronic kidney disease outpatient clinics (ACKD).
The decision to initiate renal replacement therapy (RRT) implies a wide margin of uncertainty. Glomerular filtration rate (GFR) tells us the magnitude of renal damage. Proteinuria indicates the speed of progression. However, nowadays more than 50% of patients are still initiating RRT hastily, and it is life threatening.
By analysing Emergency Department (ED) frequentation and causes of a hurried initiation, we can better schedule the timing of the start of RRT.
Retrospective and observational study of all CKD patients in our outpatient clinic. ED frequentation and hospitalization (Hos) time were reviewed during a 12-month period. We analyzed: (1) time at risk, purpose (modality of RRT), previous comorbidity; (2) causes of ED frequentation and Hos; (3) type of initiation: “scheduled” vs. “non-scheduled”, and within these “non-planned” vs. “potentially planned”.
Of a total of 267 patients (time at risk 63.987 days, 70 ± 13 years, 67% males, 38% diabetics), 68 (25%) patients came to hospital on 97 occasions: 39 only ED, 46 ED + Hos and 12 only Hos. ED frequentation was one patient every 4.3 days, and bed occupation was almost 3 per day. Main causes: 47% cardiopulmonary (1/3 heart failure), 11% vascular peripheral + cerebral, 11% gastrointestinal: 8/11 due to bleeding (all with anticoagulants/antiplatelet agents). Thirty-one (12%) patients initiated RRT: of these, 14 (45%) were scheduled (6 PD, 6 HD, and 2 living donor RTx), and 17 (55%) were not scheduled or were rushed, all with venous central catheter. Following the objectives of this study, the non-scheduled group were itemized into 2 groups: 9 non-planned (initial indication of conservative management or patient's refusal to undergo dialysis, and diverse social circumstances not controllable by the nephrologist) and 8 were considered potentially planned (6 heart failure, one gastrointestinal bleeding and one peripheral vascular complication). This last group (potentially planned), when compared with the 14 patients who started treatment in a scheduled manner, had significant differences in that they were older, with more previous cardiac events, and GFR almost double that of the other group. All of them started treatment in the ED.
This analysis provides us with knowledge on those patients who may benefit from an earlier preparation in RRT. We suggest that patients with previous cardiac events, especially with a risk of gastrointestinal bleeding, should start the preparation for RRT even with GFR rates of 20–25 ml/min. In spite of the retrospective nature of this study, and taking into account the difficulties of carrying out clinical trials in this population, we propose this suggestion as complementary to the current recommendations for a scheduled start using this technique.
La decisión de empezar tratamiento renal sustitutivo (TRS) conlleva un amplio margen de incertidumbre. El filtrado glomerular (FG) nos dice la magnitud del daño. La proteinuria, la velocidad de progresión. A pesar de estas premisas, más del 50% de los pacientes continúan iniciando TRS de forma precipitada y con riesgo vital.
Analizando la frecuentación de Urgencias (Urg) y las causas determinantes de un inicio precipitado, podremos programar mejor el momento de iniciar un TRS.
Estudio retrospectivo, observacional, de la frecuentación de Urg y del tiempo de hospitalización (Hos) de todos los pacientes de la consulta ERCA, durante un período de 12 meses. Se analizó: 1) tiempo en riesgo, destino (modalidad de TRS), comorbilidad previa. 2) Causas de frecuentación de Urg y Hos. 3) Tipo de inicio: «programado» vs. «no programado» y, dentro de estos, «no planificables» vs. «potencialmente planificables».
De 267 pacientes (con un tiempo en riesgo de 63.987 días; 70 ± 13 años; 67% varones; 38% diabéticos), 68 (25%) pacientes acudieron al hospital en 97 ocasiones: 39 solo Urg, 46 Urg + Hos y 12 solo Hos. La frecuentación de Urg fue de un paciente cada 4,3 días y la ocupación de camas fue de casi 3 diarias. Causas predominantes: 47% cardiopulmonar (1/3 insuficiencia cardíaca), 11% vascular periférico + cerebral, 11% digestivo: 8/11 por sangrado (todos con anticoagulantes/antiagregantes). Iniciaron TRS: 31 (12%): de estos, 14 (45%) de forma programada (6 DP, 6 HD y 2 TxR de donante vivo); 17 (55%) no programados o precipitados, todos con catéter venoso. Siguiendo los objetivos del estudio, estos últimos se desglosaron en 2 grupos: 9 no planificables (indicación inicial de manejo conservador o negativa del paciente a dializarse, y circunstancias sociales diversas no controlables por el nefrólogo) y 8 que consideramos potencialmente planificables (6 con fallo cardíaco, uno con hemorragia digestiva y uno vascular periférico). Estos últimos (potencialmente planificables), comparados con los 14 que iniciaron de forma programada, tenían significativamente mayor edad, más eventos cardíacos previos y el FG casi duplicaba al del otro grupo; todos entraron por Urg.
Este análisis nos aporta conocimiento sobre aquellos pacientes que pueden beneficiarse de una preparación más precoz en TRS: proponemos que en los enfermos con eventos cardíacos previos, especialmente con riesgo de sangrado digestivo, se inicie la preparación para TRS aun con tasas de FG de 20-25 ml/min. A pesar de la naturaleza retrospectiva del estudio y ante la dificultad práctica de ensayos clínicos en esta población, proponemos esta medida como complemento a las recomendaciones actuales para un inicio programado en esta técnica.

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: Supported in part by grant no. R0-1-HS09398 from the Agency for Health Care Policy and Research and the Health Care Financing Administration.

: Address reprint requests to Wolfgang C. Winkelmayer, MD, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 221 Longwood Ave, BLI/341, Boston, MA 02115. E-mail: [email protected]

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Original InvestigationsDeterminants of delayed nephrologist referral in patients with chronic kidney disease★

Abstract

Section snippets

Patients

Population and patient characteristics

Discussion

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

The timing of referral of patients with end-stage renal disease

Dial Transpl

Late diagnosis of chronic renal failure and mortality on maintenance dialysis

Nephrol Dial Transplant

Early deaths on renal replacement therapy: The need for early nephrological referral

Nephrol Dial Transplant

Early referral of CRF patients to nephrologists reduces mortality and hospitalizations

J Am Soc Nephrol

Original Investigations
Determinants of delayed nephrologist referral in patients with chronic kidney disease★