title: Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients.
abstract: BACKGROUND
  Late nephrological referral of chronic renal failure patients has been shown to be associated with high morbidity and short-term mortality on dialysis. However, the impact of predialysis nephrological care duration (PNCD) on the long-term survival of dialysis patients had not been evaluated.
  
  
  METHODS
  We studied data from all 1057 consecutive patients who started dialysis treatment at the Necker Hospital from 1989 to 1998 (mean age at start of dialysis 53.8+/-17.2 years (range 18-91 years), excluding from analysis patients who presented with acute renal failure (n=60) or advanced malignancy (n=35). We evaluated the effects of PNCD and clinical risk factors on all-cause mortality after long-term follow-up on dialysis.
  
  
  RESULTS
  Among the 1057 patients analysed (13.2% diabetics), PNCD was <6 months in 258 patients, 6-35 months in 267 patients, 36-71 months in 227 patients and >or=72 months in 307 patients. Cardiovascular (CV) morbidity, namely a history of myocardial or cerebral infarction, peripheral arteriopathy, and/or cardiac failure, before starting dialysis was 39.6% and 37.4%, respectively, in patients followed for <6 months or 6-35 months, compared with 24.4% in those followed for 36-71 months and 19.9% in those followed for >or=72 months (P<0.001). Five-year survival was significantly lower in patients with a PNCD of <6 months (59+/-4.1%) than for 36-71 months or >or=72 months (77.1+/-3.7 and 73.3+/-3.6%, respectively, P<0.001), but similar to those followed for 6-35 months (65.3+/-3.9%, NS). By Cox proportional hazard analysis, PNCD <6 months, age, diabetes and prior CV disease were independent predictive factors of all-cause death on dialysis.
  
  
  CONCLUSIONS
  This study provides suggestive evidence that longer duration of regular nephrological care in the predialysis period, at least for several years prior to the start of dialysis, is associated with a better long-term survival on dialysis. Such data strongly support the argument for early referral and regular nephrological care of chronic renal failure patients.
authors.affiliation: Department of Nephrology, Necker Hospital, Paris, France. jungers@necker.fr
authors.forename: P
authors.initials: P
authors.lastname: Jungers
authors.forename: Z A
authors.initials: ZA
authors.lastname: Massy
authors.forename: T
authors.initials: T
authors.lastname: Nguyen-Khoa
authors.forename: G
authors.initials: G
authors.lastname: Choukroun
authors.forename: C
authors.initials: C
authors.lastname: Robino
authors.forename: F
authors.initials: F
authors.lastname: Fakhouri
authors.forename: M
authors.initials: M
authors.lastname: Touam
authors.forename: A T
authors.initials: AT
authors.lastname: Nguyen
authors.forename: J P
authors.initials: JP
authors.lastname: Grünfeld
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000150:complications / Q000401:mortality; D003710:Demography; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009398:Nephrology / Q000379:methods*; D012017:Referral and Consultation; D006435:Renal Dialysis; D016019:Survival Analysis; D013997:Time Factors