RESUMO
PURPOSE: As patients with chronic renal failure are frequently referred late to nephrologists, we decided to quantify the magnitude of late referral and its consequences. METHODS: We studied retrospectively an inception cohort of 62 patients starting dialysis (either hemodialysis or continuous ambulatory peritoneal dialysis) during 1993 with a 4-year follow-up. RESULTS: The mean delay between either first symptoms of renal disease, or first evidence of renal failure and nephrologist referral was 10 years and 3 years 56 days, respectively. About 47% of the patients were referred less than 6 months before starting dialysis, and 27.5% less than 1 month. Blood pressure levels were higher in patients referred less than 6, 3 and 1 month (P < 0.05), as was creatinine concentration in patients referred less than 1 month (P < 0.05). In contrast, plasma calcium was lower for referral less than 6 months (P < 0.05) and 3 months (P < 0.005), as was bicarbonate concentration for referral less than 3 and 1 month (P < 0.05). Initial hospitalisation stay was prolonged (x1.5) for late referral less than 3 months (56.4 +/- 39 days vs 35.9 +/- 33.6 days, P < 0.05) as was 6 months hospitalisation length for referral less than 3 months (x1.6) (52.9 +/- 40.6 days vs 33.2 +/- 28.7 days, P < 0.05) and less than 1 month (x1.8) (61 +/- 45 days vs 33.9 +/- 28.7 days, P < 0.05) and < 1 month (x1.8) (61 +/- 45 days vs 33.9 +/- 28.7 days, P < 0.05). Only 44.1% of patients started hemodialysis with a functioning arteriovenous fistula, and patients requiring temporary access had a 4.4-fold longer initial (60.1 +/- 41.7 days vs 13.6 +/- 11.6 days, P < 0.005) and 6-month (59.6 +/- 39 days vs 13.6 (9.1, P < 0.005) hospitalisation stay. The four-year mortality rate was unaffected by the delayed referral but strongly and independently predicted by age, diabetes and hypoalbuminemia. CONCLUSION: Early nephrologic referral and timely initiated dialysis decrease morbidity at the start of dialysis and both hospitalisation length and costs.
