title: Late referral for dialysis: improving the management of chronic renal disease.
abstract: BACKGROUND
  Timely nephrological referral of patients with chronic renal failure (CRF) is important, but referral at a late stage of disease is common.
  
  
  OBJECTIVE
  To investigate whether late referral of patients is avoidable, and where the missed opportunities lie.
  
  
  METHODS
  Prospective ascertainment of new cases and comprehensive review of pre-end stage history.
  
  
  METHODS
  Patients admitted to Bristol and Portsmouth renal units for chronic RRT between June 1997 and May 1998 were identified from computer databases. Data were collected from case notes and hospital records, and a self-administered patient questionnaire. Late referral, defined as dialysis within 4 months of first referral to a dialysing nephrologist, was categorized by algorithm as unavoidable or avoidable.
  
  
  RESULTS
  Of 250 patients, 96 (38%) were referred late. Forty-three (45%) had definite avoidable reasons: 35 (37%) with raised serum creatinine for a median 3.7 years (IQR 1.5-8.2) before referral, and eight (8%) with risk factors for renal disease but scant assessment of renal function; 12/43 (31%) had a diagnosis of diabetic nephropathy. Late referred patients were less likely to receive standard renal therapies for chronic renal failure, were in a poorer clinical state at start of RRT, and more often required emergency dialysis, compared to patients referred early. Late referrals were as likely from a hospital as a primary care physician.
  
  
  CONCLUSIONS
  A significant proportion of patients are avoidably referred to a dialysing renal unit at a very late stage. Guidelines on referral should be developed by nephrologists, primary and secondary care physicians, and patient groups, and further research is needed into the cost-effectiveness of early referral strategies.
authors.affiliation: Health Care Research Unit, University of Southampton, Southampton General Hospital, Southampton, UK. pjr@soton.ac.uk
authors.forename: P
authors.initials: P
authors.lastname: Roderick
authors.forename: C
authors.initials: C
authors.lastname: Jones
authors.forename: C
authors.initials: C
authors.lastname: Tomson
authors.forename: J
authors.initials: J
authors.lastname: Mason
mesh_terms: D000465:Algorithms; D003695:Delivery of Health Care / Q000592:standards*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012017:Referral and Consultation / Q000592:standards*; D006435:Renal Dialysis / Q000379:methods