title: Impact of nephrology referral on early and midterm outcomes in ESRD: EPidémiologie de l'Insuffisance REnale chronique terminale en Lorraine (EPIREL): results of a 2-year, prospective, community-based study.
abstract: BACKGROUND
  Most studies looking at how the outcome of end-stage renal disease (ESRD) is affected by the timing and quality of the care received before initiation of renal replacement therapy (RRT) are inconclusive.
  
  
  METHODS
  Five hundred and two adult French patients (age, 62.8 +/- 16 years) receiving their first RRT were enrolled in a 2-year, community-based, prospective study. Subjects were assigned to 1 of 5 groups depending on the time between their first serum creatinine reading above 2 mg/dL (177 micromol/L): chronic renal failure (CRF) and nephrology referral (NR) and RRT. Multivariate logistic regression was used to analyze 90-day survival data, and data concerning long-term survival and inclusion on the waiting list for renal transplantation were analyzed using Cox proportional hazards regression.
  
  
  RESULTS
  Overall survival rates were 88% at 90 days, 77.2% at 1 year, 65.2% at 2 years, and 54.2% at 3 years. The nephrology referral pattern was associated with age and systolic blood pressure, and independently predicted early death. Compared with group 1 (NR > 12 months), odds ratios (confidence interval 95%) were 2.7 (1.2 to 6.3) for group 2 (NR < or = 12 months or >4 months), 2.8 (1.0 to 8.0) for group 3 (NR < or = 4 months or >1 month), 4.9 (2.2 to 11.0) for group 4 (NR < or = 1 month; CRF > 1 month), and 5.2 (2.2 to 12.3) for group 5 (NR < or = 1 month; CRF < or = 1 month). Independent predictors of death in 90-day survivors were age, cardiac disease with previous episodes of heart failure, vascular disease, low diastolic blood pressure, and group 3 referral pattern. Not being entered on the waiting list for renal transplantation was predicted by age, diabetes, vascular disease, and nonelective first dialysis.
  
  
  CONCLUSIONS
  Late nephrology referral is strongly associated with early death. Emergency first dialysis is an independent risk factor for not being placed on the waiting list for transplantation. Among 90-day survivors, referral pattern has little influence on mortality, which is mainly determined by cardiovascular complications at initiation of RRT.
authors.affiliation: Department of Nephrology and the Department of Clinical Epidemiology and Evaluation, University Hospital of Nancy, Nancy, France. m.kessler@chu-nancy.fr
authors.forename: Michèle
authors.initials: M
authors.lastname: Kessler
authors.forename: Luc
authors.initials: L
authors.lastname: Frimat
authors.forename: Victor
authors.initials: V
authors.lastname: Panescu
authors.forename: Serge
authors.initials: S
authors.lastname: Briançon
mesh_terms: D000367:Age Factors; D000368:Aged; D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D005602:France / Q000453:epidemiology; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000628:therapy; D016030:Kidney Transplantation / Q000706:statistics & numerical data; D015993:Life Tables; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D017582:Renal Replacement Therapy / Q000706:statistics & numerical data; D016019:Survival Analysis; D016896:Treatment Outcome; D014850:Waiting Lists