title: Early Nephrology Referral 6 Months Before Dialysis Initiation Can Reduce Early Death But Does Not Improve Long-Term Cardiovascular Outcome on Dialysis.
abstract: BACKGROUND
  There is a paucity of studies on whether early referral (ER) to nephrologist could reduce cardiovascular mortality on dialysis, and the length of pre-dialysis nephrological care needed to reduce mortality on dialysis.
  
  
  RESULTS
  A total of 604 consecutive patients who started dialysis between 2001 and 2009 in Senshu region, Osaka, Japan were analyzed. Non-linear associations between mortality and pre-dialysis duration of nephrological care were assessed using restricted cubic spline function, and predictors for death analyzed on Cox modeling. A total of 31.6%, 18.2%, 11.3% and 6.1% of patients had >12, 24, 36 and 48 months of pre-dialysis care, respectively. A total of 258 patients (42.7%) were categorized as ER (≥6 months pre-dialysis duration). During the follow-up period (median, 31.1 months), 218 patients died (cardiovascular, n=70; infection, n=69). Although patients with late referral (LR) had a proxy of inappropriate pre-dialysis care compared with the ER group, Cox multivariate analysis failed to show a favorable association between ER and cardiovascular outcome. In contrast, a deleterious effect of LR on overall survival was observed but was limited only to the first 12 months of dialysis (HR, 1.957; 95% CI: 1.104-3.469; P=0.021), but not observed thereafter.
  
  
  CONCLUSIONS
  Current pre-dialysis nephrological care may reduce short-term mortality but may not improve cardiovascular mortality after dialysis initiation.
authors.affiliation: Department of Kidney Disease and Hypertension, Osaka General Medical Center.
authors.forename: Terumasa
authors.initials: T
authors.lastname: Hayashi
authors.forename: Tomonori
authors.initials: T
authors.lastname: Kimura
authors.forename: Keiko
authors.initials: K
authors.lastname: Yasuda
authors.forename: Koichi
authors.initials: K
authors.lastname: Sasaki
authors.forename: Yoshitsugu
authors.initials: Y
authors.lastname: Obi
authors.forename: Harumi
authors.initials: H
authors.lastname: Nagayama
authors.forename: Motoki
authors.initials: M
authors.lastname: Ohno
authors.forename: Kazusei
authors.initials: K
authors.lastname: Uematsu
authors.forename: Takehiro
authors.initials: T
authors.lastname: Tamai
authors.forename: Takahiro
authors.initials: T
authors.lastname: Nishide
authors.forename: Hiromi
authors.initials: H
authors.lastname: Rakugi
authors.forename: Yoshitaka
authors.initials: Y
authors.lastname: Isaka
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000401:mortality / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D012017:Referral and Consultation; D006435:Renal Dialysis / Q000009:adverse effects*