title: Multidisciplinary chronic kidney disease management improves survival on dialysis.
abstract: BACKGROUND
  Delayed nephrology referral is associated with increased morbidity and mortality after patients begin dialysis. However, whether a pre-dialysis educational program (PEP) confers any survival advantage in comparison to unstructured specialist care is not established.
  
  
  METHODS
  Cox's regression analysis was used to estimate the association between the type of pre-dialysis follow-up and mortality in all consecutive end-stage renal disease (ESRD) adults starting dialysis therapy in two centers, between 1 January 1999 and 30 June 2002, and followed until 30 June 2003.
  
  
  RESULTS
  229 patients participated in the study. The patients tended to be male (62%), elderly (median age 70 yrs) and to have cardiovascular diseases (60%). Median follow-up on dialysis was 37.8 months, with 624 patient-yrs at risk and a 0.15 yr(-1) mortality rate. Patients receiving regular unstructured care (22.7%) appeared to have similar risk for death as late referrals (36.7%), while PEP patients (40.6%) showed longer survival (hazard ratio 0.48 (95% CI 0.27, 0.87)), allowing for demographics, comorbidities, duration of the pre-dialysis follow-up and dialysis modality. Planned dialysis commencement, a better metabolic status at dialysis initiation and the previous use of angiotensin converting enzyme inhibitors were the main factors associated with improved outcomes. The survival advantage associated with PEP was still present after late referrals or observation for < or = 1 yr were excluded, as well as when survival analysis was limited to the 1st year after dialysis initiation.
  
  
  CONCLUSIONS
  A multidisciplinary approach to chronic kidney diseases seems more effective than just timely referral to nephrologists in improving patient survival on dialysis.
authors.affiliation: Nephrology and Dialysis Division, Cremona Hospital, Cremona, Italy. p.ravani@libero.it
authors.forename: Pietro
authors.initials: P
authors.lastname: Ravani
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Marinangeli
authors.forename: Maurizio
authors.initials: M
authors.lastname: Tancredi
authors.forename: Fabio
authors.initials: F
authors.lastname: Malberti
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy*; D008297:Male; D009398:Nephrology; D010353:Patient Education as Topic; D010530:Peritoneal Dialysis / Q000401:mortality; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D006435:Renal Dialysis / Q000401:mortality; D012307:Risk Factors; D015996:Survival Rate