title: Timing of nephrology referral and initiation of dialysis as predictors for survival in hemodialysis patients: 5-year follow-up analysis.
abstract: BACKGROUND
  A consensus about the optimal timing of dialysis initiation is still controversial. Thus, the goal of this analysis was to compare outcomes in patients with early and late referral with early and late initiation of hemodialysis (HD).
  
  
  METHODS
  We studied 190 patients (mean age 52.03±14.22) who were initiated on HD between 1994 and 2004. Patients who received regular nephrology care during 12 months before HD initiation were categorized as early referrals (ER) and those without nephrology care were late referrals (LR). The early start (E-start) was defined by the estimated GFR (eGFR) at start of HD≥7.5 mL/min/1.73 m2, and the late start (L-start) by eGFR of <7.5 mL/min/1.73 m2. The four groups of patients (ER with E-start and L-start; LR with E-start and L-start) were prospectively followed in the next 60 months after HD initiation.
  
  
  RESULTS
  During the follow-up, 43.3% of E-start and 43.2% of L-start patients died, without significant difference in survival between the groups [HR for L-start vs. E-start=1.06 (95% CI 0.69-1.62); p=0.797]. When survival between ER and LR groups was compared (28.1% patients in the ER and 53.2% in the LR died), there was significant difference in survival [HR for LR vs. ER=2.16 (95% CI 1.28-3.65); p=0.004]. Compared with patients with ER and L-start, higher mortality was observed among those with LR and L-start [HR 3.51 (95% CI 1.48-8.35); p=0.004] and LR with E-start [HR 2.79 (95% CI 1.16-6.7); p=0.022]. There was no significant difference between patients in ER with L-start and ER with E-start.
  
  
  CONCLUSIONS
  Our study showed that ER above 12 months before HD initiation and L-start of dialysis was associated with a reduced mortality risk in HD patients.
authors.affiliation: University Department of Nephrology, University "Sts. Cyril and Methodius", Vodnjanska 17, 1000, Skopje, Republic of Macedonia, gjulsen_selim@yahoo.com.
authors.forename: Gjulsen
authors.initials: G
authors.lastname: Selim
authors.forename: Olivera
authors.initials: O
authors.lastname: Stojceva-Taneva
authors.forename: Goce
authors.initials: G
authors.lastname: Spasovski
authors.forename: Liljana
authors.initials: L
authors.lastname: Tozija
authors.forename: Risto
authors.initials: R
authors.lastname: Grozdanovski
authors.forename: Ljubica
authors.initials: L
authors.lastname: Georgievska-Ismail
authors.forename: Beti
authors.initials: B
authors.lastname: Zafirova-Ivanovska
authors.forename: Pavlina
authors.initials: P
authors.lastname: Dzekova
authors.forename: Lada
authors.initials: L
authors.lastname: Trajceska
authors.forename: Saso
authors.initials: S
authors.lastname: Gelev
authors.forename: Daniela
authors.initials: D
authors.lastname: Mladenovska
authors.forename: Aleksandar
authors.initials: A
authors.lastname: Sikole
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000401:mortality; D002423:Cause of Death; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D006435:Renal Dialysis; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D055815:Young Adult
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