title: [Benefits of early nephrological management in chronic renal failure].
abstract: OBJECTIVE
  We evaluated whether early nephrological referral of patients with chronic renal failure (CRF) resulted in improved condition of patients at initiation of maintenance dialysis and in better outcome on dialysis.
  
  
  METHODS
  We prospectively recorded clinical status, laboratory parameters, length of hospital stay and outcome of 900 CRF patients who started maintenance dialysis at Necker hospital between January 1989 and December 1996. We compared patients who benefited regular nephrological follow-up, and patients who were referred in emergency conditions at the ultimate stage of CRF.
  
  
  RESULTS
  Among the 900 patients, 731 (81.2%) had regular nephrological follow-up, including 632 (70.2%, group IA) with optimal preparation to dialysis and 99 (11%, group IB) whose clinical course was complicated due to heavy comorbidity, whereas 169 (18.8%, group II) had no previous nephrological management. Over the 8-year observation period, the proportion of the latter group did not decrease. Late referred patients had higher blood pressure level, more frequent fluid overload, higher serum levels of urea, creatinine, uric acid and phosphate, and lower levels of bicarbonate, calcium, albumin and creatinine clearance that did well-prepared patients. Mean (+/- SD) hospital stay was 29.7 +/- 15.8 days in the former compared to only 4.8 +/- 3.3 days (p < 0.001) in the latter. Early deaths within 3 months of dialysis initiation were more frequent (7.1 vs 1.6%, p < 0.05) and less patients subsequently were able to be treated out-center (20.1 vs 40.7%, p < 0.05) in group II than in group IA. The overcost induced by late referral may be estimated at 0.25 million French francs per patient.
  
  
  CONCLUSIONS
  An unjustified late nephrological referral of CRF patients still is observed in nearly 20% of cases. Such late referral is detrimental to both patients in terms of altered quality of life and long hospital stay, and to the collectivity due to heavy overcost. Closer cooperation between family physicians and nephrologists is needed to provide optimal management and allow timely preparation to maintenance dialysis of CRF patients.
authors.affiliation: Département de Néphrologie, Hôpital Necker, Paris. paul.jungers@nck.ap-hop.paris.fr
authors.forename: P
authors.initials: P
authors.lastname: Jungers
authors.forename: H
authors.initials: H
authors.lastname: Skhiri
authors.forename: J
authors.initials: J
authors.lastname: Zingraff
authors.forename: S
authors.initials: S
authors.lastname: Muller
authors.forename: C
authors.initials: C
authors.lastname: Fumeron
authors.forename: I
authors.initials: I
authors.lastname: Giatras
authors.forename: M
authors.initials: M
authors.lastname: Touam
authors.forename: A T
authors.initials: AT
authors.lastname: Nguyen
authors.forename: N K
authors.initials: NK
authors.lastname: Man
authors.forename: J P
authors.initials: JP
authors.lastname: Grünfeld
mesh_terms: D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000401:mortality / Q000628:therapy*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000191:economics; D013997:Time Factors; D016896:Treatment Outcome