Perit Dial Int
29(Supplement_2):
115-116
2009
© 2009 International Society for Peritoneal Dialysis
Part 3: Clinical Experiences |
OPTIMAL REFERRAL TO PRE-DIALYSIS SERVICES: ONE CENTER'S EXPERIENCE
Susan Ann Heatley
Central Manchester and Manchester Children's University Hospitals,
Manchester, U.K.
Correspondence to: S.A. Heatley, Central Manchester and Manchester Children's
University Hospital, Renal Directorate, Oxford Road, Manchester M13 9WL
England.
Susan.Heatley{at}CMMC.nhs.uk
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ABSTRACT
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The number of patients receiving renal replacement therapy in the United
Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public
health problem with significant comorbidity and mortality. Several
organizational guidelines have been developed in an attempt to identify when
appropriate referral to nephrology services should occur; however, many of
these guidelines provide conflicting recommendations on referral. Recent
surveys suggest that more than 30% of patients with CKD are referred later
than the ideal. Late referral of patients with CKD is associated with
increased patient morbidity and mortality, increased need for and duration of
hospital admission, and increased initial costs of care following commencement
of dialysis. Benefits of early referral include the identification and
treatment of reversible causes of renal impairment and management of the
multiple co-existing conditions associated with CKD. Referral time also
affects the choice of modality of treatment.
Patients and their families should receive sufficient information
regarding the nature of their CKD and options for treatment so that they can
make informed decisions concerning their care. Literature addressing the
timing of referral to low-clearance or pre-dialysis clinics is limited.
Existing data suggest that such clinics and patient education programs may
improve the medical care of patients, promote greater patient involvement in
the selection of the mode of dialysis, reduce the need for "urgent
start" dialysis, and improve short-term survival and quality of life
after initiation of dialysis. Audit of our pre-dialysis clinic has
demonstrated improved patient outcomes, and we view this service as an
essential component of the patient pathway.
KEY WORDS: CKD; late referral; early referral; pre-dialysis; patient education.
The annual acceptance rate for renal replacement therapy in the United
Kingdom is rising steadily; it rose from 110 per million population in 2005 to
113 per million population in 2006
(1). The National Service
Framework for renal services recommends that patients with chronic progressive
renal disease be referred to a multidisciplinary pre-dialysis team so as to
minimize patient morbidity and to ensure a smooth transition to appropriate
treatment pathways (2). The
adverse effects arising from late referral have been reported by nephrologists
from several countries over the past 20 years. Recognition is growing that
morbidity and mortality in end-stage renal disease are influenced by the
timing and quality of care before the initiation of dialysis.
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DEFINING LATE REFERRAL
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Referral is considered "late" when management could have been
improved by earlier contact with nephrology services. The working definition
has been referral of a patient with progressive kidney failure 1–4
months before the need to commence dialysis. However, definitions of late
referral vary, and time limits ranging from an immediate need for dialysis and
need within 6 months of referral have been cited. Several factors have been
identified that may contribute to late nephrology referral and inadequate
preparation of patients for renal replacement therapy: disease-related
factors, patient-related factors, provider-related factors, and primary care
factors (3).
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BENEFITS OF EARLY REFERRAL
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Early referral to a specialist multidisciplinary team offers many
opportunities to improve the care of patients with advance chronic kidney
disease. Those opportunities include greater choice regarding treatment
options, delay in the need to initiate renal replacement therapy, reduction in
the need for urgent dialysis, and reduction in hospital stays and hospital
costs. Moreover, the timely insertion of dialysis access can improve the
management of cardiovascular risk factors and other comorbid conditions
(4).
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REFERRAL GUIDELINES
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National guidelines speak to early referral to nephrology services; they
are not specific about when to refer to pre-dialysis services. Determining the
ideal time for referral to nephrology services is difficult to predict, with
estimated glomerular filtration rate (eGFR) being a major trigger in the
referral processes. Many existing guidelines recommend referral to a
nephrologist when the eGFR has deteriorated to 30 mL/min, but the variations
across nephrology settings are great. Guidelines for referral to a
multidisciplinary pre-dialysis team are few, probably because of the different
models of pre-dialysis care and patient management that occur across renal
establishments. In the United Kingdom, wide variations are found in the
delivery of pre-dialysis care and management of patients.
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SUMMARY
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The means by which pre-dialysis clinics improve physical and emotional
well-being are multifactorial, resulting from opportunities for patient
education, dietary counseling, modality selection, patient choice, dialysis
access formation, and management of comorbid conditions.
Our renal center has developed a pre-dialysis model of care that
incorporates locally set guidelines for nephrologists to follow for referral
into our pre-dialysis service. Criteria for referral are based on eGFR and
rate of decline in renal function in the patient. Ongoing audit of the service
has demonstrated that patients are being referred to the pre-dialysis
multidisciplinary team in a timely manner, ensuring adequate opportunity for
patient education, decision-making processes, insertion of dialysis access,
and judicious initiation of dialysis therapies.
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REFERENCES
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- Ansell D, Feehally J, Feest TG, Tomson C, Williams AJ, Warwick G,
et al. U.K. Renal Registry Report. Bristol: U.K. Renal
Registry; 2007.
- Department of Health (DH). National Service Framework for
Renal Services. Part One—Dialysis and Transplantation. London:
DH; 2005: 1-50.
- Kinchen KS, Sadler J, Fink N, Brookmeyer R, Klag MJ, Levey AS,
et al. The timing of specialist evaluation in chronic kidney disease
and mortality. Ann Intern Med 2002;137
: 479-86.[Abstract/Free Full Text]
- Ismail N, Neyra R, Hakim R. The medical and economical advantages
of early referral of chronic renal failure patients to renal specialists.
Nephrol Dial Transplant 1998;13
: 246-50.[Free Full Text]
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ABSTRACT
DEFINING LATE REFERRAL
