title: Late referral for end-stage renal disease: a region-wide survey in the south west of England.
abstract: BACKGROUND
  The proportion of patients referred for renal replacement therapy (RRT) at a late stage of disease appears to be similar to that first described nearly 20 years ago. This study investigated the current scale of the problem in a large region in England, identifying the prior health care, patient characteristics, referral pattern, and outcomes of those accepted onto RRT.
  
  
  METHODS
  Three hundred and sixty-one (88%) out of 411 patients accepted for RRT in six renal units in the South and West Region of the UK between 1 June 1996 and 31 May 1997 were studied retrospectively. We examined the history of chronic renal failure, referral path to nephrologist, management of chronic renal failure (CRF) and patient outcomes. Patients were categorized as 'late' if they were referred to the renal unit either within 4 months or within 1 month of requiring RRT.
  
  
  RESULTS
  One hundred and twenty-four (35%) patients were referred within 4 months of RRT, and 84 (23%) within 1 month. The main differences between patients referred later and other patients was seen for those referred within 1 month. These patients were older and had more co-morbidity, significantly worse laboratory parameters at the start of RRT, were less likely to have received standard treatments for CRF, had less permanent dialysis access in place at the start of RRT (18% vs 47%, P=0.001), and had a significantly longer hospital stay (18 vs 10 days, P=0.001). Seventy-four (19%) patients died in the first 6 months: 27 (32%) in the 1-month group, 46 (16%) in all others (P=0.002). We found no evidence that patients referred late had defaulted from nephrology follow-up or had an excess of rapidly progressive disease. Though data were incomplete, there was evidence of prior CRF of over 1 year in all late referral groups.
  
  
  CONCLUSIONS
  Nearly a quarter of patients are referred for specialist nephrology treatment at a very late stage, within 1 month of RRT. They are less likely to receive interventions that could alter the progression of CRF or reduce its associated co-morbidity, have a worse clinical state at the start of RRT, longer hospitalization and poorer survival. These differences were much less marked for those referred within 1-4 months of starting RRT, although this is an insufficient time to prepare for RRT. Further research is needed to determine the missed opportunities for more proactive diagnosis and management of CRF.
authors.affiliation: Health Care Research Unit, University of Southampton, Southampton General Hospital, Southampton, UK. pjr@soton.ac.uk
authors.forename: Paul
authors.initials: P
authors.lastname: Roderick
authors.forename: Chris
authors.initials: C
authors.lastname: Jones
authors.forename: Nick
authors.initials: N
authors.lastname: Drey
authors.forename: Sara
authors.initials: S
authors.lastname: Blakeley
authors.forename: Premila
authors.initials: P
authors.lastname: Webster
authors.forename: Jonathan
authors.initials: J
authors.lastname: Goddard
authors.forename: Sue
authors.initials: S
authors.lastname: Garland
authors.forename: Linda
authors.initials: L
authors.lastname: Bourton
authors.forename: Juan
authors.initials: J
authors.lastname: Mason
authors.forename: Charlie
authors.initials: C
authors.lastname: Tomson
mesh_terms: D000368:Aged; D003404:Creatinine / Q000097:blood; D004739:England / Q000453:epidemiology; D005260:Female; D005843:Geography; D006306:Health Surveys; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D017582:Renal Replacement Therapy; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D003404:Creatinine