title: Does a late referral to a nephrologist constitute a problem in children starting renal replacement therapy in Poland?--a nationwide study.
abstract: BACKGROUND
  It is estimated that 20-50% of adult patients start chronic dialysis therapy without prior contact with a nephrologist. The aim of this nationwide study was to assess clinical and metabolic status of children at the start of chronic dialysis in Poland with regard to the timing of the referral to a nephrologist.
  
  
  METHODS
  We studied data of 180 children (mean age 14+/-6 years) undergoing chronic dialysis in 13 (out of 14) dialysis pediatric centres in Poland. Patients were classified as early referrals (ERs) when they entered the dialysis programme at least 1 month after the first referral to a nephrologist or late referrals (LRs) when the dialysis was introduced within 1 month from the first visit.
  
  
  RESULTS
  Seventy-nine percent of pediatric patients were referred early (ER) to the dialysis centre and 21% were referred late (LR) and had to start dialysis within a month. When starting dialysis, LR patients had significantly higher levels of urea and phosphate as well as lower calcium and haemoglobin in comparison with ERs. Hypertension, pulmonary oedema, fluid overload, treatment in the intensive care unit (ICU) and body mass index (BMI) below 10th percentile turned out to be more frequent in the LR group. Peritoneal dialysis (PD) was used as the first method of dialysis in 59% of ERs and 46% of LRs. The majority of ER patients was treated in the predialysis period with calcitriol, phosphate binders and low protein diet (84%, 89%, 92% of all children, respectively), and 20% of them received epoetin. In the up to 3 years observation of our initial cohort, we also found that the patients who were referred late were less likely to receive kidney transplant (P = 0.02).
  
  
  CONCLUSIONS
  The results of the study indicate that the LR to a pediatric nephrologist was associated with poorer clinical and metabolic status of children entering chronic dialysis programmes.
authors.affiliation: Department of Nephrology and Dialysis, Polish Mother's Memorial Hospital Research Institute and Pediatric Nephrology Center, Tódoź, Poland.
authors.forename: Anna
authors.initials: A
authors.lastname: Jander
authors.forename: Michaeł
authors.initials: M
authors.lastname: Nowicki
authors.forename: Marcin
authors.initials: M
authors.lastname: Tkaczyk
authors.forename: Maria
authors.initials: M
authors.lastname: Roszkowska-Blaim
authors.forename: Tomasz
authors.initials: T
authors.lastname: Jarmoliński
authors.forename: Ewa
authors.initials: E
authors.lastname: Marczak
authors.forename: Ewa
authors.initials: E
authors.lastname: Pałuba
authors.forename: Jacek A
authors.initials: JA
authors.lastname: Pietrzyk
authors.forename: Grzegorz
authors.initials: G
authors.lastname: Siteń
authors.forename: Roman
authors.initials: R
authors.lastname: Stankiewicz
authors.forename: Krystyna
authors.initials: K
authors.lastname: Szprynger
authors.forename: Maria
authors.initials: M
authors.lastname: Zajaczkowska
authors.forename: J
authors.initials: J
authors.lastname: Zachwieja
authors.forename: W
authors.initials: W
authors.lastname: Zoch-Zwierz
authors.forename: D
authors.initials: D
authors.lastname: Zwolińska
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007676:Kidney Failure, Chronic / Q000628:therapy; D009398:Nephrology / Q000706:statistics & numerical data*; D011044:Poland; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D017582:Renal Replacement Therapy; D015996:Survival Rate; D013997:Time Factors