Late nephrologist referral and access to renal transplantation.
BACKGROUND
Our aim was to explore a possible association between late nephrologist referral before onset of renal replacement therapy (RRT) and the likelihood of receiving a renal transplant.


METHODS
For the period of 1991 to mid-1996 we defined an inception cohort of all patients with new-onset chronic RRT who were New Jersey Medicare and/or Medicaid beneficiaries in the year before RRT and who had been diagnosed with renal disease more than 1 year before RRT. To control for known risk factors and confounders of access to renal transplantation, we conducted a matched case-control study. Using number of days from onset of RRT to transplantation as the index date for cases, we successfully matched 32 transplant recipients (cases) with 197 controls who shared the cases' age (+/-2 years), gender, race (white/black/other), and year of onset of RRT (+/-1 year) but had not received a transplant on index date. Using conditional logistic regression, we evaluated the effects on the likelihood of transplantation of late referral (< or = 90 days vs. >90 days before first RRT) and socioeconomic status (lower socioeconomic status indicated by enrollment in Medicaid or another state program for the poor), further controlling for comorbidity (Charlson score) in the year before index date.


RESULTS
In the full multivariate conditional model, late referral was significantly associated with a much lower rate of renal transplantation (odds ratio [OR]=0.22; 95% confidence interval [CI]: 0.05, 0.97), as were socioeconomic status (OR=0.18; 95% CI: 0.04, 0.82) and comorbidity status (OR=0.69; 95% CI: 0.48, 1.00).


CONCLUSIONS
Delayed referral of renal patients to a nephrologist before RRT is significantly associated with reduced access to renal transplantation, independent of age, gender, race, socioeconomic and comorbidity status. The validity of our result needs to be confirmed in larger populations.
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. wolfgang@post.harvard.edu
Wolfgang C
WC
Winkelmayer
Robert J
RJ
Glynn
Raisa
R
Levin
Murray A
MA
Mittleman
Joseph S
JS
Pliskin
Jerry
J
Avorn
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D013997:Time Factors