[Regional epidemiology of chronic nephropathies: referral to nephrologist and initiation of dialysis]. / Epidemiologia regionale/locale delle nefropatie croniche: profili di "referral" ambulatoriale e inizio dialisi.

BACKGROUND: The epidemiology of pre-dialysis chronic nephropathies (CN) in well-defined contexts is essential to prevent delays in delivering appropriate care. METHODS: The registration of consecutive patients in seven out-patient and four in-patient dialysis centers of Basilicata (2001) formed a retrospective study on clinical charts and dialysis registers integrated with ad hoc data. RESULTS: Newly observed outpatients (I) numbered 328; prevalent patients (P) numbered 343. The age and gender of both I and P patients was similar (males: 60%, age media: 67 yr). In 316 I patients with creatinine (mean Cr: 2.3 mg/dL), the mean filtration rate (GFR) was 40.9 mL/min/1.73 m2: 13.6% were in advanced stage (S5) of GFR (<15 mL/min), 23.4% in S4/severe (15-29), 45.6% in S3/moderate (30-59), 10.8% in S2/mild (60-89), and 6.6% in S1 (>90). When compared to I patients, P patients had a mean GFR of 35.0 mL/min; S4+S5 was 48% (vs. 37%); hypertension 68% (vs. 58%); vasculopathies 15% (vs. 10%); coronary disease 10% (vs. 4%); erythropoietin 13% (vs. 7%); and low-protein diet 34% (vs. 20%) (p<0.01). Of 316 I patients, 117 in S5+S4 ('late referral' 37%) had a (mean) GFR of 18.4 mL/min, Cr 3.7 mg/dL, and were aged 70 yrs (vs. 64 yrs for 'early referral'). Of 53 new patients on dialysis, 26 (49%) were seen for the first time <6 months prior to starting (mean age: 71 yr vs. 62; female 58% vs. 26%; complications 50% vs. 17%). CONCLUSIONS: In this population, age-related factors are associated with late referral. Although sociodemographic variables depend on local contexts, these results are consistent with similar international studies. Social and cultural factors may influence physicians to postpone referring patients to a nephrologist, independently of clinical conditions.

[The need for integrated care of patients with chronic nephropathies: the epidemiology of 'late referral']. / Epidemiologia dei bisogni di gestione integrata: il "late referral" in Nefrologia.

BACKGROUND: The recent need for information has prompted this collaboration between health system epidemiologists (Basilicata) and clinicians to compare models of 'local' epidemiology in the management of diseases. The referral of patients to a nephrologist represents a working hypothesis of research- intervention. METHODS: Analysis of renal registry (RR) and administrative databases (hospital discharge abstracts/HDA, ambulatory);ad hoc surveys. RESULTS: Patients on dialysis between 1994 and 1998 are 594, cumulative deaths are 190 (32%). Males and the elderly (age = 65 years) are associated with more than 50% and threefold increase in relative risk of death, and with a diabetic nephropathy of 60% vs other renal diseases. Of 570 patients alive in 1996, 442 are linked with 2,628 HAD. Comorbid conditions are underreported in the RR (the Charlson index has been computed using HDA). Of 66 new dialysis cases, 31 are referred to a nephrologist only 6 months before the start of dialysis (47%) (22% diabetics). Patients discharged with chronic nephropathies (CN) and diabetes are 21% of CN patients (5% of diabetics). Of 100 patients with pre-end stage renal disease and diabetes, only 11-14 are discharged from the nephrology ward. At the local level, 3 out of 4 patients with serum creatinine higher than 1.5 mg/dl are not referred to a nephrologist. The prevalence of CN may vary from 0.4% to more than 1%. CONCLUSIONS: While an improvement in health databases in the regions is underway, collaboration studies are essential for planning specific interventions for prevention and management of diabetic nephropathy to improve the use of resources in nephrology.