Late referral of patients with end stage renal disease (ESRD) has resulted in increased cost, morbidity and even mortality. As the population of ESRD patient increases, it becomes more important to determine when physicians should refer those patients to a nephrologist. In an effort to examine the relationship between referral patterns and therapeutic impact on cost as well as morbidity, we analyzed renal function at the initial visit and on initiating dialysis, status of blood access, and dose of ultrafiltration at the initial dialysis. We also analyzed cost and duration of hospital stay to initiate dialysis for each referral pattern.
From 1994 to 1997, a total of 120 patients entered chronic hemodialysis therapy at this institution and these subjects were divided into three groups. 1) early referral (n=38, 61±14 yrs): referred more than one year before initiation of dialysis 2) intermediate referral (n=41, 62±10 yrs): less than 1 year and more than one month before dialysis 3) late referral (n=41, 60±13 yrs): less than one month before dialysis was initiated.
Mean hospital stay was significantly longer in the late referral group (47 days), and the daily hospital cost for initiating dialysis was higher than those of the early and intermediate groups (late: 46212 yen vs int: 38558 yen, p=.004, late vs early: 37927 yen, p=.005). Already prepared AV fistula was 82% for the early, 90% for the intermediate, 39% for the late referral group. The dose of ultrafiltration at the initial dialysis was 1.18kg for the early, 1.34kg for the intermediate, 2.0kg for the late referral group.
Our results strongly suggest that referral at the earliest opportunity would decrease cost and lower morbidity for ESRD patients.