Study identifies reasons patients referred late to nephrologists

Some patients with kidney disease aren't referred to kidney specialists in time to delay disease progression and improve their prognosis for a variety of reasons, according to researchers at Wake Forest University School of Medicine and colleagues.

An analysis of 18 separate studies found that overall, being older, belonging to a minority group, being uninsured and suffering from multiple health problems are patient characteristics associated with late referral. In addition, a lack of communication between referring physicians and nephrologists also contribute to the problem. The findings were published online this week by BioMed Central Nephrology.

Research has shown that the progression from chronic to end-stage kidney disease, which requires dialysis treatments, can be slowed if kidney damage is detected and treated early. Care by nephrologists, who specialize in treating kidney disease, is associated with reduced rates of hospitalization and death. However, studies indicate that up to 80 percent of patients who start dialysis are referred late to nephrologists.

“Late referral has been documented as a problem for more than 15 years and, according to recent studies, is not declining,” said Sonal Singh, M.D., senior author and an assistant professor of general internal medicine. “Finding ways to address the problem has been hampered by a lack of understanding of the factors responsible.”

About 26 million Americans suffer from chronic kidney disease and it is estimated that there will be 700,000 cases of end-stage kidney disease by 2015. The National Kidney Foundation recommends that patients with kidney disease be referred to nephrologists when they reach stage 4, which is a severe decrease in kidney function.

The researchers analyzed 18 studies on late referrals and looked for trends in results. They included studies that used the National Kidney Foundation's definition of “late” as well as studies using earlier definitions, such as referrals that were one, three or six months before dialysis was initiated.

Singh and colleagues found that in North America, increasing age was associated with late referral, with several studies showing that being over age 75 resulted in a late referral.

“One study showed that even being older than 55 is associated with late referral so it is prudent to assume the risk for delayed referral increases with age,” said Singh.

The researchers said that lack of provider knowledge about the appropriate timing of referral may account for more than 25 percent of late referrals.

“The study has important implications for both clinicians and policy makers,” said Singh. “In the future, referral guidelines should be prepared in collaboration with primary care physicians, and co-management approaches for chronic kidney disease need to be explored.”

Tushar Vachharajani, M.D., an interventional nephrologist at Wake Forest Baptist who was not involved in the study, said there are multiple benefits of early referral. Early treatment by a nephrologist can help slow disease progression, but even if dialysis is inevitable, an early referral gives patient and family time to plan for the treatment.

“Patients need time to prepare mentally and physically for dialysis,” he said. “Dialysis requires a 360-degree change in lifestyle.”

He also noted that end-stage kidney disease is among the most expensive to treat on a per-capital basis. “Growing health care costs makes it mandatory to practice prevention before treating a problem whenever possible,” he said.

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