title: Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States.
abstract: BACKGROUND
  Recent studies have suggested that early predialysis nephrological care is associated with lower mortality; however, this hypothesis has not been tested in a population-based study. We evaluated the impact of early nephrology referral and pre-end-stage renal disease (ESRD) care on mortality risk in a national cohort of new patients starting dialysis therapy in 1996 and 1997.
  
  
  METHODS
  Data were obtained on a subset of patients (n = 2,264; 56%) from the Dialysis Morbidity and Mortality Study Wave 2 who then were followed up for up to 2 years. Survival comparisons were made using log-rank test, then by Cox regression adjusting for demographics, comorbid medical conditions, and surrogate markers of pre-ESRD care.
  
  
  RESULTS
  Adjusted mortality risks (relative risks [RRs]) were higher for late- (within 4 months of dialysis initiation) compared with early-referred patients at the end of 1 and 2 years of follow-up (RR, 1.68; confidence interval [CI], 1.31 to 2.15; RR, 1.23; CI, 1.02 to 1.47, respectively). Mortality risks were similarly high for the late-referred nondiabetic (RR, 2.10; CI, 1.49 to 2.94) and hemodialysis subgroups (RR, 1.72; CI, 1.25 to 2.38). Conversely, mortality risks were lower for patients who saw a nephrologist at least twice in the year before dialysis therapy initiation (RR, 0.80; CI, 0.62 to 1.03; P = 0.08] compared with those who did not.
  
  
  CONCLUSIONS
  Late nephrology referral is associated with greater death risk in new patients with ESRD, and more frequent pre-ESRD care confers increased survival benefit. These findings stress the need for earlier referral of patients to nephrologists and improved pre-ESRD care for all patients approaching ESRD in the United States to improve survival. Am J Kidney Dis 41:310-318.
authors.affiliation: Department of Internal Medicine, Division of Renal Diseases and Hypertension, University of Texas Medical School-Houston, TX, 77030, USA. austin.stack@uth.tmc.edu .
authors.forename: Austin G
authors.initials: AG
authors.lastname: Stack
mesh_terms: D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000208:ethnology / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000706:statistics & numerical data / Q000639:trends; D011159:Population Surveillance / Q000379:methods; D012017:Referral and Consultation / Q000706:statistics & numerical data / Q000639:trends*; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D014481:United States / Q000453:epidemiology