Late referral to a nephrologist reduces access to renal transplantation

Alan Cass, Joan Cunningham, Paul Snelling, John Z. Ayanian

Primary care physicians frequently request consultation with a nephrologist late in the treatment of patients with chronic kidney disease (CKD). Between 25% and 40% of referred CKD patients need renal replacement therapy (RRT) within 3 months of referral to a nephrologist. Late referral is associated with higher morbidity and worse long-term survival rates. The authors examined the effect of late referral on access to renal transplantation. Data from the Australian end-stage renal disease (ESRD) registry (Australia and New Zealand Dialysis and Transplant Registry Database [ANZDATA]) regarding all ESRD patients aged 18 to 64, starting treatment between April 1995 and December 1998 were used. Excluding overseas visitors and patients commencing RRT outside Australia, the data encompassed 3,310 patients. Main outcome measures were: (1) acceptance onto a waiting list, (2) receipt of a transplant before March 31, 2000, and/or (3) receipt of a transplant during defined periods of RRT. Late referral patients were less likely to be put on the waiting list (odds ratio [OR], 0.49; 95% confidence intervals [CI], 0.41 to 0.59) or given a transplant (hazard ratio, 0.65; 95% CI, 0.55 to 0.77). Transplantation rates differed maximally during the first 3 months of RRT (OR, 0.21; 95% CI, 0.11 to 0.40) and were lower throughout RRT (OR in the period more than 2 years after commencing RRT, 0.67; 95% CI, 0.47 to 0.96). Primary care physicians should refer patients at risk for ESRD earlier than is current practice. To improve access to transplantation and to achieve optimal outcomes of ESRD management, greater collaboration will be needed between primary care physicians and nephrologists.