Late referral of patients with chronic renal insufficiency: do we nephrologists need to change our strategy?

Dipankar Bhowmik and Suresh C. Tiwari

Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India Email: dmbhowmik{at}rediffmail.com

Sir,

The editorial comment by Jungers was timely, exhaustive and thought provoking [1]. Late referral is prevalent worldwide. At our institute, in a study of 389 patients admitted with chronic renal failure, 37% of the patients were diagnosed less than three months prior to initiation of dialysis. There is no doubt that we nephrologists feel that patients who develop progressive renal insufficiency deserve an early detailed nephrological evaluation [24]. As discussed elegantly, early referral helps in nephroprotection, optimal pre-dialysis care and preparation for renal replacement therapy.

However, early referral to nephrologists on a regular basis is only possible provided that we can convince general practitioners (GPs) and internists of its importance. We feel that, so far, this aspect has been lacking. The scientific data stressing the need for early referral are published mostly in nephrology journals. It is only in the last couple of years that one finds few such publications in general medical journals [5,6]. We need to have regular interactions with GPs and internists at their conferences and publish relevant articles more frequently in journals primarily meant for them. We feel that it is this approach that will encourage our GPs and internists to refer these patients early to nephrologists.

References

  1. Jungers P. Late referral: loss of chance for the patient, loss of money for society. Nephrol Dial Transplant2002; 17: 371–375[Free Full Text]
  2. McLaughlin K, Manns B, Culleton B, Donaldson C, Taub K. An economic evaluation of early versus late referral of patients with progressive renal insufficiency. Am J Kidney Dis2001; 38: 1122–1128[ISI][Medline]
  3. Ifudu D, Dawood M, Homel P, Friedman EA. Excess morbidity in patients starting uremia therapy without prior care by a nephrologist. Am J Kidney Dis1996; 28: 841–845[ISI][Medline]
  4. Ismail N, Neyra R, Hakim R. The medical and economical advantages of early referral of chronic renal failure patients to renal specialists. Nephrol Dial Transplant1998; 13: 246–250[Free Full Text]
  5. Ellis PA, Reddy V, Bari V, Cairns HS. Late referral for ESRF. QJM1998; 91: 727–732[Abstract]
  6. McCarthy JT. A practical approach to the management of patients with chronic renal failure. Mayo Clin Proc1999; 74: 269–273[ISI][Medline]




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