[Effect of an ambulatory program devoted to chronic renal insufficiency on the reduction of mobidity and hospitalization among patients at the beginning of dialysis treatment].
BACKGROUND
Late nephrological referral of end-stage renal disease (ESRD) patients is associated with increased risk of emergent dialysis start and poor complications control. However, the relative contribution of pre-dialysis care organization is unknown.


METHODS
All 175 consecutive patients who started chronic dialysis for ESRD at our Institution from 1.1.99 to 30.6.02 were grouped as follows: referred ? 3 months before dialysis, (A, n=50); followed by non-dedicated specialists (B, n=74) or by pre-dialysis educational program personnel (PEP, n=51). We examined the first six months of hospitalization, uraemic complications control, type of dialysis initiation, and first dialysis modality.


RESULTS
There was no difference in baseline characteristics and comorbidities among groups. PEP patients had higher creatinine clearance, haemoglobin, calcemia and BMI at initiation. They also made greater use of ACE-inhibitors and were more likely to have a planned start and choose peritoneal dialysis. Emergent starts were 50% (A 100%, B 45%, PEP 4%, p<0.001). Mean pre-dialysis hospitalization (due to in-patient emergency dialysis onset for unplanned starts and planned for access insertion for elective out-patient starts) was shorter among PEP patients (7days-PEP, 17days-B, 30days-A). Logistic regression confirmed the predictive role of PEP for emergent start (AOR 0.03, 0.001 to 0.101, p<0.001) even excluding late referrals (AOR 0.1, 0.033 to 0.306, p<0.001), independently of baseline characteristics and comorbidities.


CONCLUSIONS
Pre-dialysis follow-up by dedicated personnel was more effective than traditional specialist care in reducing morbidity and health care resources utilization in patients starting dialysis.
Malberti
F
F
Divisione di Nefrologia e Dialisi, Istituti Ospitalieri, Cremona, Italy. nefrologiacr@virgilio.it
Ravani
P
P
D000328:Adult; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000453:epidemiology; D003131:Combined Modality Therapy; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000188:drug therapy / Q000453:epidemiology; D007558:Italy / Q000453:epidemiology; D007676:Kidney Failure, Chronic / Q000097:blood / Q000150:complications / Q000453:epidemiology / Q000523:psychology / Q000628:therapy*; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology; D009765:Obesity / Q000453:epidemiology; D010044:Outpatient Clinics, Hospital; D010348:Patient Care Team; D010353:Patient Education as Topic; D010530:Peritoneal Dialysis; D015397:Program Evaluation; D012017:Referral and Consultation; D006435:Renal Dialysis; D013997:Time Factors
D000806:Angiotensin-Converting Enzyme Inhibitors