Optimal referral to pre-dialysis services: one center's experience

The number of patients receiving renal replacement therapy in the United Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public health problem with significant comorbidity and mortality. Several organizational guidelines have been developed in an attempt to identify when appropriate referral to nephrology services should occur; however, many of these guidelines provide conflicting recommendations on referral. Recent surveys suggest that more than 30% of patients with CKD are referred later than the ideal. Late referral of patients with CKD is associated with increased patient morbidity and mortality, increased need for and duration of hospital admission, and increased initial costs of care following commencement of dialysis. Benefits of early referral include the identification and treatment of reversible causes of renal impairment and management of the multiple co-existing conditions associated with CKD. Referral time also affects the choice of modality of treatment. Patients and their families should receive sufficient information regarding the nature of their CKD and options for treatment so that they can make informed decisions concerning their care. Literature addressing the timing of referral to low-clearance or pre-dialysis clinics is limited. Existing data suggest that such clinics and patient education programs may improve the medical care of patients, promote greater patient involvement in the selection of the mode of dialysis, reduce the need for "urgent start" dialysis, and improve short-term survival and quality of life after initiation of dialysis. Audit of our pre-dialysis clinic has demonstrated improved patient outcomes, and we view this service as an essential component of the patient pathway.