title: Ultralate referral and presentation for renal replacement therapy: socioeconomic implications.
abstract: BACKGROUND
  Clinical and metabolic complications of late referral (LR) for dialysis therapy have been well documented, but there is a paucity of data on its socioeconomic implications. This study examines the role of lifestyle and socioeconomic status on referral pattern.
  
  
  METHODS
  During a 4-year period (1999 to 2002), we retrospectively reviewed records of all patients who initiated dialysis therapy at an urban tertiary-care center. Patients were classified into 3 categories according to the interval between first contact with a nephrologist and initiation of dialysis therapy: contact time of 3 months or longer indicates early referral (ER); 1 to less than 3 months, LR; and less than 1 month, ultralate referral (ULR).
  
  
  RESULTS
  Of 460 patients (97% African Americans, 3% Hispanics), 212 patients (46%) were ULR, 168 patients (37%) were LR, and 80 patients (17%) were ER. Compared with ER and LR patients, those with ULR had significantly (P < 0.0001) lower hematocrits (23% versus 29% and 27%), serum albumin levels (3.1 versus 3.3 and 3.2 g/dL [31 versus 33 and 32 g/L]), and glomerular filtration rates (5 versus 8 and 7 mL/min/1.73 m2 [0.08 versus 0.13 and 0.12 mL/s/1.73 m2]), but greater rates of temporary dialysis catheter use (92% versus 39% and 70%) and mortality (40% versus 15% and 26%, respectively). Logistic regression analysis showed an association between mortality and homelessness (odds ratio, 3.8; P < 0.0001), polysubstance abuse (odds ratio, 2.3; P = 0.013), and alcoholism (odds ratio, 2.2; P = 0.009). Alcoholics (odds ratio, 2.5; P = 0.03), substance abusers (odds ratio, 5.5; P = 0.001), and the homeless/unemployed (odds ratio, 6.0; P = 0.004) were more likely to present as ULR cases. Patient-provided explanations for LR and ULR were denial (45%), unawareness of the presence of chronic kidney disease (30%), and economic difficulties (25%). Denial was more prevalent in LR (52%; P = 0.003) and ULR cases (39%; P = 0.003).
  
  
  CONCLUSIONS
  Poor socioeconomic status is a major contributor to delayed referral. More efforts need to be directed at patient and physician chronic kidney disease educational awareness and improved health care access for inner-city and minority populations.
authors.affiliation: Renal Section, Clinical Research Center, Morehouse School of Medicine, Atlanta, GA 30310, USA. obialoc@msm.edu
authors.forename: Chamberlain I
authors.initials: CI
authors.lastname: Obialo
authors.forename: Elizabeth O
authors.initials: EO
authors.lastname: Ofili
authors.forename: Alexander
authors.initials: A
authors.lastname: Quarshie
authors.forename: Phyllis C
authors.initials: PC
authors.lastname: Martin
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000453:epidemiology; D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000437:Alcoholism / Q000453:epidemiology; D015897:Comorbidity; D003717:Denial, Psychological; D004522:Educational Status; D005260:Female; D005845:Georgia / Q000453:epidemiology; D005919:Glomerular Filtration Rate; D006703:Ill-Housed Persons; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000453:epidemiology / Q000208:ethnology / Q000628:therapy*; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D009398:Nephrology; D011203:Poverty; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012709:Serum Albumin / Q000032:analysis; D012959:Socioeconomic Factors; D019966:Substance-Related Disorders / Q000453:epidemiology; D013997:Time Factors; D014478:Unemployment; D014505:Urban Population
chemical_list: D012709:Serum Albumin