title: Effect of early nephrology referral on the mortality of dialysis patients in Israel.
abstract: BACKGROUND
  Late nephrology referral, before initiation of dialysis treatment, is associated with adverse outcome.
  
  
  OBJECTIVE
  To investigate the implications of late nephrology referral on mortality among dialysis patients in Israel.
  
  
  METHODS
  We retrospectively analyzed 200 incident dialysis patients. Patients were defined as late referrals if they started dialysis less than 3 months after their first nephrology consultation. Survival rates and risk factors for mortality were analyzed
  
  
  RESULTS
  The early referral (ER) group comprised 118 patients (59%) and the late referral (LR) group 82 patients (41%). The mortality rate was 44.5% (53 patients) in the ER and 68% (n = 56) in the LR group. The 4 year survival rate was 41.1% in the ER and 18.7% in the LR group (P < 0.0001). The mortality rate increased with late nephrology referral (HR 1.873, 95% CI 1.133-3.094), with age (HR 1.043 for each year, 95% CI 1.018-1.068), with diabetes (HR 2.399, CI 1.369-4.202), and with serum albumin level (HR 0.359 for an increase of each 1 g/dl, 95% CI 0.242-0.533). The median survival time was higher for the ER group in women, in patients younger than 70, and in diabetic patients. A trend for longer survival time was found in non-diabetic patients. Survival time was not increased in early referred patients older than 70 and in male patients.
  
  
  CONCLUSIONS
  Late nephrology referral is associated with an overall higher mortality rate in dialysis patients. The survival advantage of early referral may have a different significance in specific subgroups. The timing of nephrology referral should be considered as a modifiable risk factor for mortality in patients with end-stage renal disease.
authors.forename: Noa Berar
authors.initials: NB
authors.lastname: Yanay
authors.forename: Lubov
authors.initials: L
authors.lastname: Scherbakov
authors.forename: David
authors.initials: D
authors.lastname: Sachs
authors.forename: Nana
authors.initials: N
authors.lastname: Peleg
authors.forename: Yakov
authors.initials: Y
authors.lastname: Slovodkin
authors.forename: Regina
authors.initials: R
authors.lastname: Gershkovich
mesh_terms: D000368:Aged; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D007557:Israel / Q000453:epidemiology; D008297:Male; D009398:Nephrology / Q000379:methods*; D017063:Outcome Assessment, Health Care; D011379:Prognosis; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000379:methods / Q000706:statistics & numerical data; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors