Ultralate referral and presentation for renal replacement therapy: socioeconomic implications

Am J Kidney Dis. 2005 Nov;46(5):881-6. doi: 10.1053/j.ajkd.2005.08.003.

Abstract

Background: Clinical and metabolic complications of late referral (LR) for dialysis therapy have been well documented, but there is a paucity of data on its socioeconomic implications. This study examines the role of lifestyle and socioeconomic status on referral pattern.

Methods: During a 4-year period (1999 to 2002), we retrospectively reviewed records of all patients who initiated dialysis therapy at an urban tertiary-care center. Patients were classified into 3 categories according to the interval between first contact with a nephrologist and initiation of dialysis therapy: contact time of 3 months or longer indicates early referral (ER); 1 to less than 3 months, LR; and less than 1 month, ultralate referral (ULR).

Results: Of 460 patients (97% African Americans, 3% Hispanics), 212 patients (46%) were ULR, 168 patients (37%) were LR, and 80 patients (17%) were ER. Compared with ER and LR patients, those with ULR had significantly (P < 0.0001) lower hematocrits (23% versus 29% and 27%), serum albumin levels (3.1 versus 3.3 and 3.2 g/dL [31 versus 33 and 32 g/L]), and glomerular filtration rates (5 versus 8 and 7 mL/min/1.73 m2 [0.08 versus 0.13 and 0.12 mL/s/1.73 m2]), but greater rates of temporary dialysis catheter use (92% versus 39% and 70%) and mortality (40% versus 15% and 26%, respectively). Logistic regression analysis showed an association between mortality and homelessness (odds ratio, 3.8; P < 0.0001), polysubstance abuse (odds ratio, 2.3; P = 0.013), and alcoholism (odds ratio, 2.2; P = 0.009). Alcoholics (odds ratio, 2.5; P = 0.03), substance abusers (odds ratio, 5.5; P = 0.001), and the homeless/unemployed (odds ratio, 6.0; P = 0.004) were more likely to present as ULR cases. Patient-provided explanations for LR and ULR were denial (45%), unawareness of the presence of chronic kidney disease (30%), and economic difficulties (25%). Denial was more prevalent in LR (52%; P = 0.003) and ULR cases (39%; P = 0.003).

Conclusion: Poor socioeconomic status is a major contributor to delayed referral. More efforts need to be directed at patient and physician chronic kidney disease educational awareness and improved health care access for inner-city and minority populations.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Acquired Immunodeficiency Syndrome / epidemiology
  • Adult
  • African Americans / statistics & numerical data
  • Aged
  • Alcoholism / epidemiology
  • Comorbidity
  • Denial, Psychological
  • Educational Status
  • Female
  • Georgia / epidemiology
  • Glomerular Filtration Rate
  • Homeless Persons
  • Humans
  • Kidney Failure, Chronic / economics
  • Kidney Failure, Chronic / epidemiology
  • Kidney Failure, Chronic / ethnology
  • Kidney Failure, Chronic / therapy*
  • Male
  • Medically Underserved Area
  • Middle Aged
  • Nephrology
  • Poverty
  • Referral and Consultation / statistics & numerical data*
  • Renal Dialysis / statistics & numerical data*
  • Retrospective Studies
  • Serum Albumin / analysis
  • Socioeconomic Factors*
  • Substance-Related Disorders / epidemiology
  • Time Factors
  • Unemployment
  • Urban Population

Substances

  • Serum Albumin