Unfavorable effects of history of volume overload and late referral to a nephrologist on mortality in patients initiating dialysis: a multicenter prospective cohort study in Japan

Abstract

BackgroundPatients with late referral and positive history of volume overload may have a poor prognosis after initiating dialysis due to insufficient and/or inadequate management of complications of renal failure and the lack of better dialysis preparation. Little is known about the influence of the relationship between history of volume overload and late referral on prognosis.MethodsWe analyzed 1475 patients who had initiated dialysis for the first time from October 2011 to September 2013. late referral was defined as referral to a nephrologist < 3 months before dialysis initiation. The major outcomes were all-cause death and deaths due to cardiovascular diseases (CVD). The impact of late referral and history of volume overload on all-cause mortality was assessed by Cox proportional hazards models.ResultsAmong 1475 patients, the mean patient age was 67.5 years. During the median follow-up of 2.2 years, 260 deaths occurred; 99 were due to CVD. Cox proportional hazards models demonstrated that late referral (adjusted hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.00–1.82) and history of volume overload (adjusted HR, 1.39; 95% CI, 1.06–1.81) were risk factors for all-cause mortality. Furthermore, late referral coexisting was associated with a history of volume overload increased mortality (adjusted HR, 2.10; 95% CI, 1.39–3.16 versus absence of late referral without history of volume overload) after adjusting for age, sex, diabetes, atherosclerotic disease, and laboratory values.ConclusionsBoth late referral and history of volume overload were associated with increased risks of all-cause mortality.Trial registrationUniversity Hospital Medical Information Network (UMIN000007096). Registered 18 January 2012, retrospectively registered.https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000008349.Electronic supplementary materialThe online version of this article (10.1186/s12882-018-0859-8) contains supplementary material, which is available to authorized users.

Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline

“…Dialysis is therefore the core of this model, and pre-dialysis care develops around it, which is mainly in order to prepare patients for dialysis start ( Figure 2 ). Other activities, such as interventional nephrology and post-transplant, or even care for rare diseases, are ancillary to well-functioning dialysis activity [ 27 , 28 , 29 , 36 , 37 , 38 , 39 ]. The development of these latter activities mainly depends on the preferences of each group, but can be limited by a lack of hospitalization facilities.…”

“…The advantage of focusing on dialysis, probably nephrology’s most “specific specificity “, which overall in Europe treats between 400 and 700 patients per million population, is clear. The goals of integrating the care of CKD are not only to prepare patients for dialysis and to orient them to the different treatments that are available in a cost-effective (and sometimes gain-effective) manner, but also to offer a continuum of care, particularly important in the transition phases between pre-dialysis and dialysis care [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ].…”

“…There is an urgent need for more research in this field, including an analysis of the results of similar procedures and treatments (including hospitalization, Figure 6 ) in nephrology units and other settings (for instance internal medicine), before pressure to reduce specialist activity leads to an irreversible loss of expertise in our discipline, as it occurred, for instance, for vascular access, whose expertise shifted from being mainly nephrologists’ to mainly a task of vascular surgeons, or for early stages of diabetic nephrology or hypertensive diseases, now mainly followed in internal medicine or endocrinology. The lack of efficiency of leaving these competences out of the Nephrology specialty are reflected by the lack of decrease not only of patients needing renal replacement therapy, but also of late referral of patients with end stage kidney diseases, even in these two contexts [ 28 , 29 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ].…”

“…A great deal of indirect evidence supports this model, advocated by most scientific associations [ 63 , 64 , 65 , 66 , 67 ]. Early referral, timely diagnosis, life-style changes, and education have all been linked to slower CKD progression and improved survival [ 28 , 29 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 68 , 69 , 70 , 71 , 72 , 73 ].…”

“…Given the extreme heterogeneity of kidney diseases, it is not easy to find a satisfactory algorithm for identifying patients with potentially progressive diseases so that they can be referred to a specialist. As stated above, in most European countries over 30% of patients start dialysis in emergency and with suboptimal care and this high prevalence clearly shows the limits of present CKD care [ 26 , 36 , 37 , 38 , 39 , 40 ]. The example of the prevalence of dialysis incidence in the United States, which is almost twice as high as Canada’s (after correction for case-mix), is the best large-scale demonstration of the importance of pre-dialysis care, widely available in Canada, but sadly lacking in the U.S. [ 32 ].…”