Consequences of late referral on patient outcomes

There is growing awareness of a need not only to identify patients with chronic renal failure (CRF) at an earlier stage in the disease process, but also to initiate treatment strategies earlier, in order to delay both progression of CRF and co-morbid diseases and to define the optimal time required to prepare CRF patients for renal replacement therapy (RRT). These three strategies are linked, and rely on appropriate identification of patients at risk of renal disease. The challenge currently facing nephrologists is both how to minimize the consequences of late referral and how to improve the timeliness of referral. Published studies support the notion that outcomes are poor in patients who access specialized nephrology care late in the course of their renal disease (just prior to the need for dialysis). A National Institute of Health consensus publication recommends early referral to a multidisciplinary renal care team, and the recent Canadian Society of Nephrology guidelines recommend that at least 12 months are needed prior to initiation of dialysis for adequate medical and psychological preparation for RRT. Despite these recommendations, a substantial proportion (20-50%) of patients starts dialysis without prior exposure to nephrologists. Limited data exist on current referral patterns to nephrologists. Diabetes and/or hypertension cause renal disease in up to 40% of patients requiring dialysis. These patients are presumably being monitored by internists, endocrinologists or cardiologists, and many referrals come from these physicians; other patients may be referred by general practitioners. Data regarding disease status at the time of referral are also limited. Substantial cardiovascular disease and risk factors are evident at the time of referral. Most of the literature describes data for those starting dialysis (i.e. late referral) rather than a broader spectrum of all patients with renal insufficiency referred to nephrologists. Reasons for late referral include insensitivity of current screening tools. Serum creatinine is well known to be an inaccurate marker of renal dysfunction, and too insensitive to identify patients with very early stages of disease, thus contributing to the prevalence of late referrals. Physician and patient attitudes are other barriers to early referral and need to be studied more fully. The consequences of late referrals include increased morbidity, mortality, and resource utilization. There is also an impact on patients' quality of life and missed opportunities for pre-emptive transplantation. Late referral also limits therapeutic options, and these limitations have consequences on long-term outcomes once patients are on dialysis. It is clear that late referral of patients with CRF obviates the opportunity for significant delay of disease progression and institution of proactive strategies to reduce the overall burden of illness in the population. There is ample evidence that strategies to delay progression of renal disease are effective, as are strategies to reduce cardiovascular disease. Anaemia and a fall in haemoglobin concentration have been associated with left ventricular hypertrophy and with growth of the left ventricle. A combined approach is necessary for best nephrological clinical practice, with a clear definition of early renal insufficiency; this will involve the development of tools to permit early identification of patients with early renal insufficiency, and the implementation of strategies to optimize treatments aimed at both delaying progression and preparing patients for RRT.