Clinical research studyOutcomes of Early versus Late Nephrology Referral in Chronic Kidney Disease: A Systematic Review
Section snippets
Methods
A systematic review protocol (CD007333) was written and published in Issue 3, 2009 of the Cochrane Renal group.2 A systematic search was conducted to identify published studies of outcomes in patients with chronic kidney disease receiving dialysis, including timing of referral to nephrology services. Key search terms are listed in the supplementary electronic table (Table 1, online); no limits were used. The following databases were searched (search dates included): MEDLINE (1966 to September
Results
Our search identified 114 studies; 9 duplicate studies were removed and 14 were excluded based upon title or abstract. Full manuscripts of 91 papers were obtained and data were extracted from 27 studies; of the other 64 studies, 30 did not have relevant outcome measures, 19 were review articles, 6 were studies of acute renal failure, 5 were pediatric studies, and 4 did not meet our definition of early referral (Figure 1). The 27 included studies had 17,646 participants; 11,734 were referred
Discussion
Our meta-analysis showed that patients referred earlier to nephrology services had reduced mortality and hospitalization. The benefits seen in the earlier referred patients appear to be acquired independently of differences in traditional cardiovascular risk factors such as prior coronary artery disease, diabetes mellitus, systolic and diastolic blood pressures, lipid profile, and renal biochemistry. It appears that better fistula preparation and placement of dialysis access may explain
Conclusions
Patients referred earlier to a nephrologist demonstrate significantly reduced short- and long-term mortality, hospitalization, and anemia, as well as better dialysis preparation. Our data suggest that blood pressure, serum phosphate, and serum albumin appear to be managed equally by specialist and nonspecialist physicians. Neither did our analysis find any differences in the prevalence of comorbid illness often reported with late referral. Our analyses suggest that reduced mortality and
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Funding: The first author, Neil Smart, was funded by the Commonwealth Government of Australia's Department of Health and Aging Primary Healthcare Research Evaluation and Development program (2006-2009) during the time he undertook the work, with no influence on the study design, data collection, analysis, interpretation, or on the decision to submit.
Conflict of Interest: None.
Authorship: Both authors had equal access to data and contributed equally to the work and manuscript.