Timing of nephrology referral: A study of its effects on the likelihood of transplantation and impact on mortality

Delayed referral of patients with end-stage renal disease (ESRD) to a nephrologist is associated with considerable early morbidity and increased mortality. The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) has collected data regarding the timing of referral to a nephrologist for all patients beginning renal replacement therapy (RRT) since 1 April 1995. We examined survival and likelihood of transplantation for patients who started RRT between 1 April 1995 and 31 December 1998, with follow-up until 31 March 2000 (up to 5 years follow-up). Of 4886 patients starting RRT, 1277 (26.1%) were in the late referral (LR) group and 3609 (73.9%) were not (NLR). In a multivariate analysis, predictors of LR were age 0–44 years and the presence of two or more comorbidities. Ninety days after referral, 60% of patients in the LR group were on haemodialysis compared with 55% of patients in the NLR group; 40% of patients in each group were receiving peritoneal dialysis at this time. Patients in the LR group were significantly less likely to receive a transplant in the first year after referral and throughout the duration of the study compared with the NLR group. Mortality rates were 19 and 13 persons per 100 patient years in the LR and NLR groups, respectively. In conclusion, delayed referral to a nephrologist was associated with increased mortality which continued for up to 5 years, even after adjustment for known predictors of mortality including age, sex, comorbidities and primary renal disease.