title: Referral to nephrologists for chronic kidney disease care: is non-diabetic kidney disease ignored?
abstract: BACKGROUND
  Late referral to nephrologists is common and associated with increased morbidity and mortality. We aimed to analyze the prevalence rates, predictors and consequences of late referral to nephrologists by primary care physicians for chronic kidney disease (CKD) care.
  
  
  METHODS
  A retrospective analysis of 204 patients started on dialysis for CKD in two community hospitals between March 2003 and March 2005 was conducted. Relevant clinical and laboratory data were obtained from the patient records of the nephrology clinics and dialysis units. Patients referred in CKD stage 5 (estimated glomerular filtration rate <15 ml/min) were defined as late referral and patients in CKD stage 1-4 (estimated glomerular filtration rate >15 ml/min) as early referral.
  
  
  RESULTS
  Forty-five (22%) of the 204 patients were referred late. In the multivariate analysis, non-diabetic kidney disease (odds ratio = 2.46, p = 0.02) and Charlson comorbidity index (odds ratio = 1.17, p = 0.009) were significantly associated with late referral. The late referral group had lower hematocrit and serum calcium levels, and higher serum phosphorus and parathyroid hormone levels than the early referral group (p < or =0.05) at the time of referral. Late referral resulted in less permanent vascular access for initiation of dialysis (p = 0.03). Even though there was twice the number of deaths in the late referral group in 1 year (18 vs. 9%), this was not statistically significant (p = 0.07).
  
  
  CONCLUSIONS
  Referring physicians should pay special attention to patients with non-diabetic kidney disease and patients with multiple comorbidities since delayed referral to nephrologists may result in poorer patient-related outcomes. Larger and long-term prospective studies analyzing the long-term consequences of late referral to nephrologists are needed.
authors.affiliation: Division of Nephrology, University of Rochester, Rochester, NY 14642, USA. sankardass@hotmail.com
authors.forename: Sankar D
authors.initials: SD
authors.lastname: Navaneethan
authors.forename: Sagar
authors.initials: S
authors.lastname: Nigwekar
authors.forename: Mohan
authors.initials: M
authors.lastname: Sengodan
authors.forename: Edwin
authors.initials: E
authors.lastname: Anand
authors.forename: Sarika
authors.initials: S
authors.lastname: Kadam
authors.forename: Vinodh
authors.initials: V
authors.lastname: Jeevanantham
authors.forename: Marvin
authors.initials: M
authors.lastname: Grieff
authors.forename: Wajid
authors.initials: W
authors.lastname: Choudhry
mesh_terms: D000328:Adult; D000368:Aged; D002908:Chronic Disease; D005260:Female; D006801:Humans; D007674:Kidney Diseases / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009398:Nephrology / Q000706:statistics & numerical data*; D009518:New York; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care; D011320:Primary Health Care / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012044:Regression Analysis; D012189:Retrospective Studies; D013997:Time Factors