Survival benefit of nephrologic care in patients with diabetes mellitus and chronic kidney disease

Arch Intern Med. 2008 Jan 14;168(1):55-62. doi: 10.1001/archinternmed.2007.9.


Background: The association of nephrologic care and survival in patients with diabetes mellitus and chronic kidney disease is unknown.

Methods: Using data from 1997 to 2000, we conducted a retrospective cohort study of Veterans Health Administration clinic users having diabetes mellitus and stage 3 or 4 chronic kidney disease. The baseline period was 12 months and median follow-up was 19.3 months. Degree of consistency of visits to a nephrologist, defined as the number of calendar quarters in which there was 1 visit or more (range, 0-4 quarters), and covariates were calculated from the baseline period. The outcome measure was dialysis-free death.

Results: Of 39,031 patients, 70.0%, 22.4%, and 7.6% had early stage 3, late stage 3, and stage 4 chronic kidney disease, respectively, and 3.1%, 9.5%, and 28.2%, respectively, visited a nephrologist. Dialysis-free mortality rates were 9.6, 14.1, and 19.4, respectively, per 100 person-years. More calendar quarters with visits to a nephrologist were associated with lower mortality: adjusted hazard ratios were 0.80 (95% confidence interval, 0.67-0.97), 0.68 (95% confidence interval, 0.55-0.86), and 0.45 (95% confidence interval, 0.32-0.63), respectively, when the groups having 2, 3, and 4 visits were compared with those who had no visits. One visit only was not associated with a difference in mortality when compared with no visits (adjusted hazard ratio,1.02; 95% confidence interval, 0.89-1.16).

Conclusions: The consistency of outpatient nephrologic care was independently associated in a graded fashion with lower risk of deaths in patients with diabetes and moderately severe to severe chronic kidney disease. However, only a minority of patients had any visits to a nephrologist.

Publication types

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

MeSH terms

  • Aged
  • Aged, 80 and over
  • Ambulatory Care
  • Cohort Studies
  • Diabetes Mellitus / mortality*
  • Diabetes Mellitus / therapy*
  • Female
  • Humans
  • Kidney Failure, Chronic / mortality*
  • Kidney Failure, Chronic / therapy*
  • Male
  • Nephrology
  • Referral and Consultation
  • Retrospective Studies
  • Survival Rate