title: Suboptimal initiation of dialysis with and without early referral to a nephrologist.
abstract: BACKGROUND
  Our objective was to examine patients who initiate renal replacement therapy (RRT) at 10 representative Canadian centers, characterize their initiation as inpatient or outpatient and describe their initial type of dialysis access, duration of pre-dialysis care and clinical status at the time of dialysis initiation. We also examined the impact of an optimal dialysis start (i.e. initiated as an outpatient with an arteriovenous fistula, arteriovenous graft or peritoneal dialysis catheter) on subsequent health outcomes.
  
  
  METHODS
  Charts of consecutive incident RRT patients were identified from 1 July to 31 December 2006. Information was collected until 6 months after the initiation or until death, transplant or transfer.
  
  
  RESULTS
  Three hundred and thirty-nine incident RRT patients were studied: 39.6% initiated as an inpatient; 54% started hemodialysis (HD) with a central venous catheter; 15.3% had <1 month predialysis care, while 64.6% had >1 year. Optimal starts occurred in 39.5% of patients. For HD patients, optimal starts occurred in 19.8%. Suboptimal starts were noted in patients referred <12 months prior to end-stage renal disease (44%) and in patients referred earlier (56%). The composite end point of death, transfusion or subsequent hospitalization was significantly reduced with an optimal start [hazard ratio 0.47 (95% confidence interval 0.32-0.68), P = 0.0001].
  
  
  CONCLUSIONS
  Suboptimal initiation of dialysis is common in patients referred early or late. The benefits of early referral are lost if dialysis is initiated suboptimally. There is a need to identify factors that lead to suboptimal initiation despite early referral.
authors.affiliation: Department of Nephrology, Humber River Regional Hospital and University of Toronto, Toronto, Canada. dmendelssohn@hrrh.on.ca
authors.forename: David C
authors.initials: DC
authors.lastname: Mendelssohn
authors.forename: Bryan
authors.initials: B
authors.lastname: Curtis
authors.forename: Karen
authors.initials: K
authors.lastname: Yeates
authors.forename: Serge
authors.initials: S
authors.lastname: Langlois
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: MacRae
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Semeniuk
authors.forename: Fernando
authors.initials: F
authors.lastname: Camacho
authors.forename: Philip
authors.initials: P
authors.lastname: McFarlane
mesh_terms: D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D011379:Prognosis; D011446:Prospective Studies; D012017:Referral and Consultation; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D017582:Renal Replacement Therapy; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate