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      Early Referral to a Nephrologist Improved Patient Survival: Prospective Cohort Study for End-Stage Renal Disease in Korea


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          The timing of referral to a nephrologist may influence the outcome of chronic kidney disease patients, but its impact has not been evaluated thoroughly. The results of a recent study showing an association between early referral and patient survival are still being debated. A total of 1028 patients newly diagnosed as end-stage renal disease (ESRD) from July 2008 to October 2011 were enrolled. Early referral (ER) was defined as patients meeting with a nephrologist more than a year before dialysis and dialysis education were provided, and all others were considered late referral (LR). The relationship of referral pattern with mortality in ESRD patients was explored using a Cox proportional hazards regression models. Time from referral to dialysis was significantly longer in 599 ER patients than in 429 LR patients (62.3±58.9 versus 2.9±3.4 months, P<0.001). Emergency HD using a temporary vascular catheter was required in 485 (47.2%) out of all patients and in 262 (43.7%) of ER compared with 223 (52.0%) of LR (P = 0.009). After 2 years of follow-up, the survival rate in ER was better than that in LR (hazard ratio [HR] 2.38, 95% confidence interval [CI] 1.27–4.45, P = 0.007). In patients with diabetes nephropathy, patient survival was also significantly higher in ER than in LR (HR 4.74, 95% CI 1.73–13.00, P = 0.002). With increasing age, HR also increased. Timely referral to a nephrologist in the predialytic stage is associated with reduced mortality.

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          Comorbidity, urea kinetics, and appetite in continuous ambulatory peritoneal dialysis patients: their interrelationship and prediction of survival.

          Comorbidity, urea kinetics (Kt/V and normalized protein catabolic rate), dietary protein, total calorie intake, and plasma albumin were measured in 97 continuous ambulatory peritoneal dialysis patients followed prospectively for 30 months. Comorbid disease was graded severe in 12 patients, intermediate in 29, and absent in 56. At entry to the study comorbidity was associated with increased age (P = 0.001), lower dietary protein (P = 0.015) and calorie intake (P = 0.02), and a lower plasma creatinine (P = 0.026). Trends toward lower Kt/V and albumin were not significant, and normalized protein catabolic rate was unaffected. Ability of these measures to predict mortality was assessed by univariate and multivariate analysis using Cox's proportional hazard model. On univariate analysis, comorbidity (P < 0.0001), age (P = 0.0001), Kt/V (P = 0.009), plasma albumin (P = 0.009), calorie intake (P = 0.035), and dietary protein intake (P = 0.03) predicted outcome, whereas normalized protein catabolic rate did not (P = 0.46). Multivariate analysis indicated that comorbidity (P = 0.0003) and age (P = 0.0085) were the only independent predictors of outcome. The addition of plasma albumin and Kt/V increased the significance of the Cox model. Further analysis of comorbidity demonstrated the relative importance of vascular disease and left ventricular dysfunction. This study illustrates the profound influence of comorbid disease on mortality in continuous ambulatory peritoneal dialysis patients and suggests that it causes suppression of appetite independent of the dialysis dose.
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            Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: an observational cohort study.

            Late nephrologist referral may adversely affect outcome in patients initiating maintenance hemodialysis therapy, mostly with temporary catheters that may further increase morbidity and mortality. Our aim was to evaluate the influence of 2 variables on mortality: presentation mode (planned versus unplanned) and type of access (arteriovenous fistula [AVF] versus temporary catheter) at entry. This was a 3-center, 5-year, prospective, observational, cohort study of 538 incident patients. Measurements included presentation mode, type of access, renal function and biochemical test results at entry, and stratification of risk groups. Main outcome measures were mortality and hospitalization. Of 281 planned patients (52%), 73% initiated therapy with an AVF. Of 257 unplanned patients (48%), 70% initiated therapy with a catheter (P < 0.001). Multivariate Cox analysis showed that unplanned presentation (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.23 to 2.44) and initiation of therapy with catheter (HR, 1.75; 95% CI, 1.25 to 2.46) were independently associated with greater mortality and similar HRs after adjusting for confounders. At 12 months, the number of deaths was 3 times higher in both the unplanned versus planned groups and catheter versus AVF groups. The joint effect of unplanned dialysis initiation and catheter use had an additive impact on mortality (HR, 2.89; 95% CI, 1.97 to 4.22). Greater hematocrit (HR, 1.04; 95% CI, 1.01 to 1.09) and albumin level (HR, 1.79; 95% CI, 1.37 to 2.33) showed an independent association with survival, underscoring the benefits of predialysis care. Using Poisson regression, all-cause hospitalization (incidence rate ratio, 1.56; 95% CI, 1.36 to 1.79; P < 0.001) and infection-related (incidence rate ratio, 2.62; 95% CI, 1.91 to 3.59; P < 0.001) and vascular access-related (incidence rate ratio, 1.49; 95% CI, 1.15 to 1.94; P < 0.003) admissions were higher in unplanned patients initiating therapy with a catheter than in planned patients initiating therapy with an AVF, after adjusting for confounders. Unplanned dialysis initiation and temporary catheter were independently associated with greater mortality rates in incident patients. The combined influence of both variables was associated with greater morbidity and mortality than either variable alone.
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              Timing of nephrologist referral and arteriovenous access use: the CHOICE Study.

              Recent clinical practice guidelines recommend the creation of an arteriovenous (AV) vascular access (ie, native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complication-prone dialysis catheters. We report on the association of referral to a nephrologist with duration of dialysis-catheter use and type of vascular access used in the first 6 months of hemodialysis therapy. The study population is a representative cohort of 356 patients with questionnaire, laboratory, and medical record data collected as part of the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease Center Study. Patients who reported being seen by a nephrologist at least 1 month before starting hemodialysis therapy (75%) were more likely than those referred later to use an AV access at initiation (39% versus 10%; P < 0.001) and 6 months after starting hemodialysis therapy (74% versus 56%; P < 0.01). Patients referred within 1 month of initiating hemodialysis therapy used a dialysis catheter for a median of 202 days compared with 64, 67, and 19 days for patients referred 1 to 4, 4 to 12, and greater than 12 months before initiating hemodialysis therapy, respectively (P trend < 0.001). Patients referred at least 4 months before initiating hemodialysis therapy were more likely than patients referred later to use an AV fistula, rather than a synthetic graft, as their first AV access (45% versus 31%; P < 0.01). These associations remained after adjustment for age, sex, race, marital status, education, insurance coverage, comorbid disease status, albumin level, body mass index, and underlying renal diagnosis. These data show that late referral to a nephrologist substantially increases the likelihood of dialysis-catheter use at the initiation of hemodialysis therapy and is associated with prolonged catheter use. Regardless of the time of referral, only a minority of patients used an AV access at the initiation of treatment, and greater than 25% had not used an AV access 6 months after initiation. Thus, further efforts to improve both referral patterns and preparation for dialysis after referral are needed.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                25 January 2013
                : 8
                : 1
                [1 ]Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
                [2 ]Department of Dental Hygiene, College of Health Science, Eulji University, Seongnam, Korea
                [3 ]Department of Epidemiology and Biostatistics, School of Public Health, Seoul National University, Seoul, Korea
                [4 ]Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
                [5 ]Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
                [6 ]Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
                [7 ]Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
                [8 ]Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
                [9 ]Clinical Research Center for End Stage Renal Disease in Korea, Daegu, Korea
                Sookmyung Women's University, Republic of Korea
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: DHK JPL. Performed the experiments: YLK SWK CWY NHK YSK. Analyzed the data: MK HK. Wrote the paper: DHK YSK JPL.


                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 10
                This study was supported by a grant from the Korea Healthcare Technology R& D Project, Ministry for Health and Welfare, Republic of Korea (A102065). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Research Article
                Population Biology
                Economic Epidemiology
                Life Course Epidemiology
                Social Epidemiology
                Clinical Research Design
                Cohort Studies
                Economic Epidemiology
                Lifecourse Epidemiology
                Social Epidemiology
                Chronic Kidney Disease



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