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Mutatiri C, Ratsch A, McGrail M, Venuthurupalli SK, Chennakesavan SK. Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review. BMC Nephrol 2024; 25:149. [PMID: 38689219 PMCID: PMC11061991 DOI: 10.1186/s12882-024-03585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease. OBJECTIVE The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process. METHODS A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023. RESULTS Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early. CONCLUSIONS This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.
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Affiliation(s)
- Clyson Mutatiri
- Renal Medicine, Wide Bay Hospital and Health Service, Bundaberg, QLD, Australia.
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Bundaberg, QLD, Australia.
| | - Angela Ratsch
- Research Services, Wide Bay Hospital and Health Service, Hervey Bay, QLD, Australia
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Hervey Bay, QLD, Australia
| | - Matthew McGrail
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Rockhampton, QLD, Australia
| | - Sree Krishna Venuthurupalli
- Kidney Service, Department of Medicine, West Moreton Hospital and Health Service, Ipswich, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Milkowski A, Prystacki T, Marcinkowski W, Dryl-Rydzynska T, Zawierucha J, Malyszko JS, Zebrowski P, Zuzda K, Małyszko J. Lack or insufficient predialysis nephrology care worsens the outcomes in dialyzed patients - call for action. Ren Fail 2022; 44:946-957. [PMID: 35652160 PMCID: PMC9176675 DOI: 10.1080/0886022x.2022.2081178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The phenomenon of patients with advanced renal failure accepted for dialysis at a late stage in the disease process (late referral [LR]) is known almost from the beginning of dialysis therapy. It may also be associated with worse outcomes. The aim of the study was to assess the effect of referral time on the outcomes, such as number of hospitalizations, length of stay, kidney transplantation, and mortality. A study of 1303 patients with end-stage renal failure admitted for dialysis in the same period in Fresenius Nephrocare Poland dialysis centers was initiated. The type of vascular access during the first dialysis was accepted as the criterion differentiating LR (n = 457 with acute catheter) from early referral (ER; n = 846). The primary endpoint was the occurrence of death during the 13-month observation. By the end of observation, 341 (26.2%) of patients died. The frequency of death was 18.1 for ER and 37.9 for LR per 1000 patient-months. It can be estimated that 52.1% (95% CI: 40.5–61.5%) of the 341 deaths were caused by belonging to the LR group. Patients from LR group had longer hospitalizations, more malignancies, lower rate of vascular access in the form of a–v fistula, higher comorbidity index. It seems that establishing a nephrological registry would help to improve the organization of care for patients with kidney disease, particularly in the pandemic era.
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Affiliation(s)
| | | | | | | | | | - Jacek S Malyszko
- 1st Department of Nephrology and Transplantology, Medical University of Bialystok, Białystok, Poland
| | - Pawel Zebrowski
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warszawa, Poland
| | - Konrad Zuzda
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warszawa, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warszawa, Poland
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Effect of Nephrology Care on Mortality in Incident Dialysis Patients: A Population-Based Cohort Study. J Pers Med 2021; 11:jpm11111071. [PMID: 34834424 PMCID: PMC8622450 DOI: 10.3390/jpm11111071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 12/02/2022] Open
Abstract
Long-term and continuous nephrology care effects on post-dialysis mortality remain unclear. This study aims to systematically explore the causal effect of nephrology care on mortality for patients with dialysis initiation. We conducted a retrospective cohort study to include incident patients with dialysis for ≥ 3 months in Taiwan from 2004 through 2011. The continuous nephrology care of incident patients in the three years before their dialysis was measured every six months. Continuous nephrology care was determined by 0–6, 0–12, …, 0–36 months and their counterparts; and none, intermittent, 0–6 months, …, and 0–36 months. Simple and weighted hazards ratio (HR) and 95% confidence interval (CI) for one-year mortality were estimated after propensity score (PS) matching. We included a total of 44,698 patients (mean age 63.3 ± 14.2, male 51.9%). Receiving ≥ 1 year predialysis nephrology care was associated with a 22% lower post-dialysis mortality hazard. No different effects were found (ranges of PS matching HR: 0.77–0.80) when comparing the defined duration of nephrology care with their counterparts. Stepped survival benefits were newly identified in the intermittent care, which had slightly lower HRs (weighted HR: 0.88, 95% CI: 0.79–0.97), followed by reviving care over six months to two years (ranges of weighted HR: 0.60–0.65), and reviving care over two years (ranges of weighted HR: 0.48–0.52). There was no existing critical period of nephrology care effect on post-dialysis, but there were extra survival benefits when extending nephrology care to >2 years, which suggests that continuous and long-term care during pre-dialysis/chronic kidney disease phase is required.
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Herrera-Añazco P, Ortiz PJ, Peinado JE, Tello T, Valero F, Hernandez AV, Miranda JJ. In-hospital mortality among incident hemodialysis older patients in Peru. Int Health 2020; 12:142-147. [PMID: 31294777 PMCID: PMC7057138 DOI: 10.1093/inthealth/ihz037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/08/2018] [Accepted: 04/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Understanding the pattern of mortality linked to end stage renal disease (ESRD) is important given the increasing ageing population in low- and middle-income countries. METHODS We analyzed older patients with ESRD with incident hemodialysis, from January 2012 to August 2017 in one large general hospital in Peru. Individual and health system-related variables were analyzed using Generalized Linear Models (GLM) to estimate their association with in-hospital all-cause mortality. Relative risk (RR) with their 95% confidence intervals (95% CI) were calculated. RESULTS We evaluated 312 patients; mean age 69 years, 93.6% started hemodialysis with a transient central venous catheter, 1.7% had previous hemodialysis indication and 24.7% died during hospital stay. The mean length of stay was 16.1 days (SD 13.5). In the adjusted multivariate models, we found higher in-hospital mortality among those with encephalopathy (aRR 1.85, 95% CI 1.21-2.82 vs. without encephalopathy) and a lower in-hospital mortality among those with eGFR ≤7 mL/min (aRR 0.45, 95% CI 0.31-0.67 vs. eGFR>7 mL/min). CONCLUSIONS There is a high in-hospital mortality among older hemodialysis patients in Peru. The presence of uremic encephalopathy was associated with higher mortality and a lower estimated glomerular filtration rate with lower mortality.
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Affiliation(s)
- Percy Herrera-Añazco
- Universidad San Ignacio de Loyola, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru.,Departamento de Nefrologia, Hospital Nacional 2 de Mayo, Lima, Peru
| | - Pedro J Ortiz
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jesus E Peinado
- Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Tania Tello
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Fabiola Valero
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Adrian V Hernandez
- University of Connecticut/Hartford Hospital Evidence-based Practice Center, Hartford, CT, USA.,Universidad San Ignacio de Loyola, Unidad de Revisiones Sistemáticas y Meta anáñisis, Guias de Práctica Clínica y Evaluaciones Tecnológicas Sanitarias, Lima, Peru
| | - J Jaime Miranda
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Gerontología, Universidad Peruana Cayetano Heredia, Lima, Peru.,CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
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Chen JH, Chiu YW, Hwang SJ, Tsai JC, Shi HY, Lin MY. Effect of nephrology referrals and multidisciplinary care programs on renal replacement and medical costs on patients with advanced chronic kidney disease: A retrospective cohort study. Medicine (Baltimore) 2019; 98:e16808. [PMID: 31415394 PMCID: PMC6831162 DOI: 10.1097/md.0000000000016808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Evidence-based studies have revealed outcomes in patients with chronic kidney disease that differed depending on the design of care delivery. This study compared the effects of 3 types of nephrology care: multidisciplinary care (MDC), nephrology care, and non-nephrology care. We studied their effects on the risks of requiring dialysis and the differences between these methods had on long-term medical resource utilization and costs.We conducted a retrospective cohort study involving patients with an estimated glomerular filtration rate of (eGFR) ≤45 mL/min/1.73 m from 2005 to 2007. Patients were divided into MDC, non-MDC, and non-nephrology referral groups. Between-group differences with regard to the risk of requiring dialysis and annual medical utilization and costs were evaluated using a 5-year follow-up period.In total, 661 patients were included. After other covariates and the competing risk of death were taken into account, we observed a significant (56%) reduction in the incidence of dialysis in both the MDC and non-MDC groups relative to the non-nephrology referral group. Costs were markedly lower in the MDC group relative to the other groups (average savings: US$ 830 per year; 95% confidence interval: 367-1295; P < .001).For patients without nephrology referrals, MDC can substantially reduce their risk of developing end-stage renal disease and lower their medical costs. We therefore strongly advocate that all patients with an eGFR of ≤45 mL/min/1.73 m should be referred to a nephrologist and receive MDC.
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Affiliation(s)
- Jui-Hsin Chen
- Department of Nursing, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Hospital
- Department of Healthcare Administration and Medical Informatics, College of Health Sciences
| | - Yi-Wen Chiu
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital
- Department of Renal Care, College of Medicine
| | - Shang-Jyh Hwang
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital
- Department of Renal Care, College of Medicine
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
- Institute of Population Sciences, National Health Research Institutes, Miaoli
| | - Jer-Chia Tsai
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital
- Department of Renal Care, College of Medicine
| | - Hon-Yi Shi
- Department of Healthcare Administration and Medical Informatics, College of Health Sciences
| | - Ming-Yen Lin
- Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital
- Department of Renal Care, College of Medicine
- Master of Public Health Degree Program, College of Public Health, National Taiwan University, Taipei, Taiwan
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Early mortality in patients with chronic kidney disease who started emergency haemodialysis in a Peruvian population: Incidence and risk factors. Nefrologia 2018; 38:425-432. [PMID: 30032858 DOI: 10.1016/j.nefro.2017.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 09/04/2017] [Accepted: 11/09/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To estimate early mortality in patients with chronic kidney disease who started emergency haemodialysis between 2012 and 2014 in a national referral hospital in Lima, Peru, and to identify risk factors. DESIGN, CHARACTERISTICS, PARTICIPANTS AND MEASUREMENTS A retrospective cohort study was conducted by reviewing the medical records of all patients admitted to the hospital's Haemodialysis Unit from 2012 to 2014. Early mortality, defined as death within the first 90 days of starting haemodialysis, as well as age, gender, chronic kidney disease aetiology, comorbidities, cause of death, estimated glomerular filtration rate, vascular access and other variables were evaluated in patients who initiated emergency haemodialysis. Early mortality was estimated using frequencies and risk factors were determined by Poisson regression with robust variance. RESULTS 43.4% of patients were female, 51.5% were aged≥65 years and the early mortality rate was 9.3%. The main risk factors were estimated glomerular filtration rate>10 ml/min/1.73m2 (RR: 2.72 [95% CI: 1.60-4.61]); age≥65 years (RR: 2.51 [95% CI: 1.41-4.48]); central venous catheter infection, RR: 2.25 (95% CI: 1.08-4.67); female gender, RR: 2.15 (95% CI: 1.29-3.58); and albumin<3.5g/dl (RR: 1.97 [95% CI: 1.01-3.82]). CONCLUSIONS Early mortality was 9.3%. The main risk factor was starting haemodialysis with an estimated glomerular filtration rate>10ml/min/1.73m2.
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Eckardt KU, Gillespie IA, Kronenberg F, Richards S, Stenvinkel P, Anker SD, Wheeler DC, de Francisco AL, Marcelli D, Froissart M, Floege J. High cardiovascular event rates occur within the first weeks of starting hemodialysis. Kidney Int 2015; 88:1117-25. [PMID: 25923984 PMCID: PMC4653589 DOI: 10.1038/ki.2015.117] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 02/12/2015] [Accepted: 02/26/2015] [Indexed: 12/25/2022]
Abstract
Early mortality is high in hemodialysis (HD) patients, but little is known about early cardiovascular event (CVE) rates after HD initiation. To study this we analyzed data in the AROii cohort of incident HD patients from over 300 European Fresenius Medical Care dialysis centers. Weekly rates of a composite of CVEs during the first year and monthly rates of the composite and its constituents (coronary artery, cerebrovascular, peripheral arterial, congestive heart failure, and sudden cardiac death) during the first 2 years after HD initiation were assessed. Of 6308 patients that started dialysis within 7 days, 1449 patients experienced 2405 CVEs over the next 2 years. The first-year CVE rate (30.2/100 person-years; 95% CI, 28.7-31.7) greatly exceeded the second-year rate (19.4/100; 95% CI, 18.1-20.8). Composite CVEs were highest during the first week with increased risk compared with the second year, persisting until the fifth month. Except for sudden cardiac death, temporal patterns of rates for all CVE categories were very similar, with highest rates during the first month and a high-risk period extending to 4 months. Higher or lower cumulative weekly dialysis dose, lower blood flow, and lower net ultrafiltration during dialysis were associated with CVE during the high-risk period, but not during the post high-risk period. Thus, the incidence of CVE in the first weeks after HD initiation is much higher than during subsequent periods which raises concerns that HD initiation may trigger CVEs.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Florian Kronenberg
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Peter Stenvinkel
- Department of Renal Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre, Göttingen, Germany
| | | | - Angel L de Francisco
- Servicio de Nefrología, Hospital Universitario Valdecilla, Universidad de Cantabria, Santander, Spain
| | | | | | - Jürgen Floege
- Division of Nephrology and Immunology, Department of Medicine, RWTH University of Aachen, Aachen, Germany
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