Advances in Chronic Kidney Disease
Volume 14, Issue 3 , Pages e27-e34, July 2007

Early Start Peritoneal Dialysis

  • Carol A. Pollock

      Affiliations

    • Department of Renal Medicine, Kolling Institute, University of Sydney, Royal North Shore Hospital, St. Leonards, NSW, Australia
    • Corresponding Author InformationAddress correspondence to Carol Pollock, MD, University of Sydney, Department of Medicine, Royal North Shore Hospital, St. Leonards, NSW 2065, Australia.
    • ,
  • Bruce A. Cooper

      Affiliations

    • Department of Renal Medicine, Kolling Institute, University of Sydney, Royal North Shore Hospital, St. Leonards, NSW, Australia
    • ,
  • David C. Harris

      Affiliations

    • Department of Renal Medicine, Millenium Institute, University of Sydney, Westmead Hospital, Wentworthville, NSW, Australia.

Article Outline

The timing of commencement of dialysis is controversial, as it has an impact on the patient’s lifestyle, the dialysis capacity of renal services, and costs to both the individual and community. In patients with chronic kidney disease, the commencement of dialysis based on clinical features of uremia and laboratory indices that mandate dialysis therapy may not optimize outcomes. Currently reported studies are subject to potential confounding factors, including lead-time bias, the timing of referral, uniform predialysis care, patient age, comorbidity, and compliance. Despite the lack of supporting evidence, national and international expert panels have generally recommended adopting guidelines that support the initiation of dialysis at levels of kidney function that are higher than observed in current practice. No compelling evidence supports the initial use of one modality of dialysis over another, but initiation of peritoneal dialysis will likely preserve residual kidney function to a greater extent than will initiation of hemodialysis. As preservation of endogenous kidney function is an important goal in patients with end-stage kidney disease, this outcome may contribute to the choice of modality. Objective parameters that will guide the initiation of dialysis to maximize survival, reduce morbidity, and inform as to the economic benefit of implementing such practice will be available when the Initiating Dialysis Early and Late (IDEAL) study reports in 2009.

Index Words: Early-start, Peritoneal dialysis

 

The optimal time to commence dialysis in patients with chronic kidney disease is not clear. This uncertainty has been recognized by nephrologists internationally as potentially the most important dialysis-related question to be addressed in the next decade. A number of groups have tried to resolve the issue of when to commence dialysis by use of either cohort or case-control studies.1, 2, 3, 4, 5, 6 These investigations have, in general, supported the concept that starting dialysis with a relatively higher level of kidney function affords a benefit with respect to morbidity, mortality, capacity for employment, and quality of life. However, these studies are subject to potential confounding factors, including lead-time bias, the timing of referral, uniform predialysis care, patient age, comorbidity, and compliance. As a result, no firm conclusion can be reached about the optimal time to start dialysis. Indeed the largest cohort study reported to date concluded that despite the need for an adequately powered randomized trial to address this issue, such a trial would be unlikely ever to occur.7 We have initiated and fully recruited such a trial (Initiating Dialysis Early and Late [the IDEAL trial]), with results expected in 2009.8 This trial should provide key information to patients, clinicians, and health economists as to the optimal time to commence renal replacement therapy.

Back to Article Outline

Current Guidelines 

Despite the lack of supporting evidence, guidelines have been issued by national bodies and international expert panels recommending the initiation of dialysis at a level of kidney function much higher than is currently practiced. The Kidney Disease Outcomes and Quality Initiatives (KDOQI) of the National Kidney Foundation of the USA9 has recommended that dialysis be commenced at a glomerular filtration rate (GFR) of approximately 10.5 mL/min/1.73 m2, a level based on the minimum target level of total (residual renal and dialysis) clearance for peritoneal dialysis, unless all 3 of the following criteria are met: stable or increased edema-free body weight; no evidence of malnutrition; and absence of clinical signs and symptoms of uremia. The European Best Practice Guidelines recommend that dialysis should be commenced whenever uremia is present or when blood pressure or hydration status cannot be controlled. In the absence of these indications, dialysis should commence at a GFR between 8 to 10 mL/min to avoid the creatinine clearance falling below 8 mL/min/1.73 m2 or the GFR below 6 mL/min/1.73 m2.10 The Canadian Society of Nephrology11 has recommended that dialysis be commenced when GFR falls below 12 mL/min, with a provision that dialysis can be deferred if no evidence of uremia or malnutrition is present. The Caring for Australians with Renal Impairment (CARI) guidelines, developed under the auspices of the Australian and New Zealand Society of Nephrology and the Australian Kidney Foundation12 recommend dialysis at a GFR of 10 mL/min or less, with the discretion to start later if malnutrition or symptoms of uremia are absent. Data from the United States13 and Australia and New Zealand14 show that dialysis is currently commenced well below these targets.

Back to Article Outline

The IDEAL Trial 

The primary objective of the IDEAL trial is to determine whether the early initiation of dialysis reduces all-cause mortality in patients with end-stage kidney disease. The secondary objectives are to determine if early initiation of dialysis is associated with a reduction in morbidity (infections and cardiovascular disease, including echocardiographic parameters), associated with dialysis complications (access problems, fluid and electrolyte disorders, and the requirement for temporary dialysis access), reduces overall treatment costs, reduces hospitalization days, alters loss of residual kidney function, and improves quality of life and nutritional state. The broader economic impact of “early-start” versus “late-start” dialysis is additionally being assessed.

The study has enrolled over 800 patients drawn from 32 participating units in Australia and New Zealand. Patients were enrolled into the study if they were aged 18 years or older, had progressive kidney disease, and had a GFR at baseline of 10 to 20 mL/min/1.73 m2. Once the GFR fell to 15 mL/min/1.73m2, patients were randomized to early-start or late-start dialysis and observed every 3 months from randomization. “Early-start” patients were targeted to commence dialysis with a GFR 10 to 14 mL/min/1.73 m2 and “late-start” patients when the GFR reached 7 mL/min/1.73 m2. Hence, the study is appropriately designed to address the issue of whether elective early-start dialysis improves morbidity and mortality and at what cost.

Back to Article Outline

Why Start Dialysis Early? 

The case for starting dialysis early is based on the incongruous observation that we allow endogenous renal clearances to fall below the minimal clearances that we target once dialysis has commenced. The rationale for commencing dialysis once renal clearance falls below this minimal value is largely derived from secondary analyses of large-scale cohort studies. The CANUSA study demonstrated that 1-year and 2-year survival was greater in patients commencing dialysis with more preserved levels of kidney function. The relative risk of death was 0.95 (95% CI, 0.91 to 0.99) for a 5 L/wk greater GFR at initiation15 In a retrospective analysis, commencing dialysis early (mean creatinine clearance 13 mL/min versus late 2.1 mL/min) resulted in better mean 12-year survival (77% v 51%), less hospitalization (7 days v 16 days per year), and greater employment (72% v 42%). In a subsequent longitudinal study of 90 patients well matched for comorbidity, degree of kidney dysfunction, and length of follow up in the predialysis period, these differences in survival and morbidity were not easily explained by lead-time bias, age, or kidney disease.3 A follow-up of a subset of the patients who were subsequently transplanted demonstrated a survival advantage for those who had commenced dialysis early.4 Additional studies demonstrate that delayed referral to a nephrologist, resulting in late commencement of dialysis, is associated with a worse outcome.6 However, the converse has also been observed in that incident patients who start dialysis at greater levels of GFR had more comorbid conditions and a 42% greater mortality compared with patients who commenced dialysis with lower levels of GFR.16 The difference in outcome was not fully explained by the additional comorbidity. Moreover, a 25% increased risk of mortality in commencing dialysis early was observed in older patients, and a 39% increased risk was observed in patients without diabetes mellitus, heart failure, or vascular disease. The effect of lead-time bias in studies demonstrating that patients who commence dialysis earlier and, hence, survive longer on dialysis was adjusted for by Traynor et al,7 who measured survival from the time of an estimated GFR of 20 mL/min, independent of the timing of dialysis. In multivariate analysis an 11% increase in risk of death was seen for each 1 mL/min higher GFR at the time of initiation of dialysis. In a further study, Beddhu et al17 also demonstrated a 14% increased mortality risk for each 5 mL/min increase in GFR, calculated by the MDRD equation,18 at the start of dialysis, but this result was not confirmed when a direct measure of creatinine clearance was used as the estimate of kidney function.

In light of the evidence that a decline in kidney function is associated with a spontaneous reduction in protein intake,19 that those commencing dialysis late have a poor nutritional profile,20 and that increased mortality is observed in patients commencing renal replacement therapy with a low serum albumin, an early start of renal replacement therapy has been suggested to improve nutrition.2, 21, 22 The Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) is a multicenter, prospective cohort study that includes adult patients who commence either hemodialysis or peritoneal dialysis and who are then observed until transplantation or death. The NECOSAD study group has explored the presumed interaction between protein intake and kidney function in a cohort of 114 incident-dialysis patients. Only 10% of the cohort fulfilled the KDOQI recommendations for initiation of dialysis with a Kt/V of greater than 2.0/wk. Despite this circumstance, 69% met the recommended protein-nitrogen appearance target of greater than 0.8 g/kg/d, which demonstrated the “mismatch” between renal clearance and protein intake in this population.23

The cost implications of varying the time renal replacement therapy is commenced is at present not clear and will be defined in the economic evaluation of the IDEAL study. Simulated cohort studies suggest that early referral results in cost savings, improved patient survival, and reduced inpatient stays.24 The cost-effectiveness decreased as rates of kidney-function loss for patients referred early versus late approximated each other, which suggests that an early start of dialysis is likely to have an economic benefit.

Back to Article Outline

Trends in Timing of Initiation of Dialysis 

A trend for the earlier commencement of dialysis has occurred in Europe, the United States, and Canada in the last decade of the twentieth century.13, 25, 26

Patients enrolled in the NECOSAD study have trended toward earlier initiation of dialysis over time. Despite this development, no difference in survival or health-related quality of life has been observed.27 A paucity of data on the timing of dialysis in pediatric patients exists. Relatively recent data derived from the United States Renal Data Systems have shown that children commence dialysis with more preserved kidney function than do adults. Approximately 50% of children who commence dialysis do so with a GFR of greater than 10 mL/min/1.73 m2. In contrast, 7.3% commence dialysis with a GFR less than 5 mL/min/1.73 m2. Over the period 1995 to 2002, a steady increase occurred in the percentage of children commencing dialysis at higher levels of kidney function. No difference in GFR was observed between patients who initiated hemodialysis compared with peritoneal dialysis.28

Does a Preferred Mode of Dialysis at Initiation Exist? 

The mode of dialysis therapy is best decided by a fully informed patient with due consideration given to comorbidities that may influence the choice of therapy and resource availability. Hemodialysis induces a decline in kidney function within the first 3 months of dialysis,23 and residual kidney function has an important effect on survival.29, 30 Although earlier initiation of dialysis could possibly lead to a more rapid loss of endogenous clearance and accelerate morbidity and mortality, this risk appears to be less if peritoneal dialysis (in particular, continuous ambulatory peritoneal dialysis) is used as the initial form of therapy.31, 32 Automated peritoneal dialysis (APD) may be associated with a more precipitous decline in residual kidney function. In a small prospective study of 36 patients, endogenous creatinine clearance declined more rapidly in the first year in patients on APD compared with CAPD.33

Patients referred for dialysis late in the course of disease have more often been treated with hemodialysis than with peritoneal dialysis. This outcome has been at least in part because of the ease of placing a temporary catheter for vascular access and the ability to use it immediately after placement. However, newer approaches to peritoneal catheter placement by use of fluoroscopy-assisted percutaneous techniques,34, 35 or minilaparotomy plus omentopexy36 have enabled easier catheter placement with the opportunity to commence dialysis within days rather than weeks.

In light of studies that demonstrate an initial survival advantage in patients commencing peritoneal dialysis,37 an integrated-care approach has been advanced: start dialysis with peritoneal and transfer to hemodialysis if complications arise.38

Empirical and theoretical arguments have proposed that initiating dialysis in incremental doses may be sufficient to maintain clearances and limit the time commitment inherent in dialysis. Incremental dialysis is practical for patients commencing peritoneal dialysis, by initially utilizing 1 overnight exchange when the GFR is between 10 and 12 mL/min and increasing the exchanges as endogenous kidney function declines.39 Implementation of incremental dialysis requires careful monitoring of residual kidney function, with potentially frequent changes in dialysis prescription to avoid underdialysis. No trials have compared outcomes in patients initiating dialysis with incremental versus full-dose dialysis.

Late Referral Versus Late Dialysis 

Given the lack of randomized trials, the effect of late referral to a nephrologist versus the elective late commencement of dialysis is difficult to delineate in the literature. Although a randomized trial that compares late or early referral to a nephrologist would be impossible to conduct, cohort studies suggest that late referral and nonelective commencement of dialysis results in a 1.6-fold to 4.9-fold increased morbidity and mortality in both the diabetic and nondiabetic populations.40, 41, 42, 43, 44, 45, 46 The Dialysis Outcomes and Practice Patterns Study (DOPPS) demonstrated that predialysis nephrology care for patients treated with hemodialysis resulted in a 50% lower rate of cardiac death and withdrawal from dialysis during the first 120 days of dialysis therapy when compared with patients who did not receive predialysis nephrology care. No difference in mortality was observed in the subsequent 121 to 365 days.47 In the peritoneal population, early referral to a nephrologist is associated with improved biochemical parameters, reduced length of stay for first hospitalization, and a higher percentage of elective catheter placements.48 Although the majority of the excess risk occurs in the first 90 to 120 days after commencement of dialysis, data from the Australian and New Zealand Dialysis Registry demonstrated an increased mortality risk for patients who are referred late that persists beyond the first year of dialytic therapy.49 Furthermore, patients who are referred late have a reduced likelihood of being placed on the cadaveric transplant waiting list and receiving a transplant. The difference is maximal within the first 3 months of commencing dialysis, but remains significant for up to 2 years of dialysis therapy.50

Despite the evidence that supports early referral to a nephrology unit, unfortunately, the incidence of late referrals has not diminished over the past 5 years and still accounts for more than 30% of patients who commence dialysis.51 Approximately 25% of patients who enter end-stage renal failure programs in Australia and New Zealand commence dialysis late,52 which is similar to European data, but the percentage is potentially higher in North American centers.41, 44, 45, 53 Despite European data to the contrary,54 late referrals were surprisingly equally likely to occur in the younger and older population in Australia and New Zealand (ANZDATA), but this observation may be the result of patients coming from socioeconomically disadvantaged areas.55 The majority of late referrals occur in patients with known kidney disease. In a study that specifically assessed patients with a known history of kidney disease for more than 12 months but with no nephrologic contact for more than 90 days before the start of dialysis, a 37% increased risk of death occurred in the first year of dialysis.56

Late referral for dialysis is not restricted to the adult population. Pediatric patients who commence dialysis late have poorer metabolic and clinical status compared with patients referred earlier for renal replacement therapy.57 These studies emphasize the need for education among primary-care physicians and patients.

Australian studies have highlighted that patients are more likely to be referred late if they come from a socially disadvantaged background.55 Studies based in North America have demonstrated that patients who are black, uninsured, and have severe comorbidities are more likely to present for late evaluation.58 Pediatric studies have demonstrated that women, nonwhite minority populations, and those without medical insurance are likely to start dialysis late28 Clearly, physicians and patients resist early referral and the reasons underpinning these attitudes need to be more fully explored.

Back to Article Outline

Influence of Predialysis Management 

Referral to a nephrologist has a positive impact on metabolic and hematologic parameters, on a planned start of dialysis, on consideration for preemptive transplantation, and on management of comorbidites (Table 1).50, 58, 59, 60, 61, 62, 63 Additionally the opportunity exists to implement strategies to delay the progression of kidney failure and to reduce the overall burden of illness in the population. In the study by Kessler and coworkers,41 more prolonged predialysis care was positively associated with a higher hemoglobin and albumin and more stable calcium and phosphate control.

Table 1. Potential Benefits of Early Referral to a Nephrologist
Metabolic and Hematologic Parameters
Regulation of calcium, phosphate, and parathyroid hormone homeostasis
Correction of metabolic acidosis
Correction of anemia with appropriate attention to erythropoetic-stimulating agents and iron therapy
Nutritional advice
Planned Transition to Renal Replacement Therapy
Informed choice of dialysis modality
Timely placement of access (peritoneal catheter of arteriovenous fistula)
Planned commencement of dialytic therapy
Assessment of the appropriateness of preemptive transplantation
Social supports in place
Management of “Nonrenal” Risks
Appropriate blood pressure management
Assessment and management of vascular disease and heart failure

The lack of an arteriovenous fistula at the start of hemodialysis decreases survival.64 The value of a mature access and avoidance of a temporary or permanent catheter is reinforced by DOPPS data47 that showed commencing dialysis with catheter access increased mortality by 62%, which was only exceeded if dialysis commenced at 75 years of age or older, with congestive heart failure or with HIV/AIDS.

Despite enthusiasm for early nephrology referral, studies suggest that almost 60% of patients seeing nephrologists commence dialysis with a serum albumin less than 35 g/L,58 and anemia management is less than optimal.59 Recent data suggest that an experienced nurse practitioner, working to dedicated protocols, is more likely to achieve the desired outcomes than is referral to a service in which multiple nephrology trainees are responsible for patient care.65 Furthermore, referral to a multidisciplinary clinic is likely to be more effective in achieving outcomes than is referral to a single nephrologists.66 Implementation of a predialysis clinical pathway in Melbourne, Australia has recently been shown to reduce the percentage of inadequately prepared patients commencing dialysis from 29% to 6% and the corresponding median time from registration to commencement of dialysis from less than 1 month to 14 months. The proportion of patients commencing dialysis with permanent vascular access increased proportionately from 24% to 83%.67 The observed improvement was the result of a multidisciplinary approach, rather than referral to a nephrologist per se.

Back to Article Outline

Conclusions 

The reasons underpinning the timing of initiation and mode of dialysis in patients with end-stage chronic kidney disease are complex. Clearly a proportion of patients will present “late,” and the opportunity to consider the timing of dialysis is limited. Improved education of patients and physicians to date has had limited impact on the problem of “late referrals.” A dedicated approach to the smooth transition onto dialysis improves outcomes. Whether this approach includes the early initiation of dialysis will be defined by the results of the IDEAL Study.

Back to Article Outline

References 

  1. McCusker FX, Teehan BP, Thorpe KE, et al. Canada-USA (CANUSA) Peritoneal Dialysis Study Group How much peritoneal dialysis is required for the maintenance of a good nutritional state?. Kidney Int. 1996;56(suppl):S56–S61
  2. Tattersall J, Greenwood R, Farrington K. Urea kinetics and when to commence dialysis. Am J Nephrol. 1995;15:283–289
  3. Bonomini V, Feletti C, Scolari MP, et al. Benefits of early initiation of dialysis. Kidney Int. 1985;17(suppl):S57–S59
  4. Bonomini V, Feletti C, Stefoni S, et al. Early dialysis and renal transplantation. Nephron. 1986;44:267–271
  5. Jungers P, Zingraff J, Albouze G, et al. Late referral to maintenance dialysis: Detrimental consequences. Nephrol Dial Transplant. 1993;8:1089–1093
  6. Sesso R, Belasco AG. Late diagnosis of chronic renal failure and mortality on maintenance dialysis. Nephrol Dial Transplant. 1996;11:2417–2420
  7. Traynor JP, Simpson K, Geddes CC, et al. Early initiation of dialysis fails to prolong survival in patients with end-stage renal failure. J Am Soc Nephrol. 2002;13:2125–2132
  8. Cooper BA, Branley P, Bulfone L, et al. The Initiating Dialysis Early and Late (IDEAL) study: Study rational and design. Perit Dial Int. 2004;24:176–181
  9. NKF-DOQI: Clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Am J Kidney Dis. 2007;49(suppl 2):S12–S154
  10. The initiation of dialysis. Nephrol Dial Transplant. 2005;20(suppl 9):ix3–ix7
  11. Churchill DN, Blake PG, Jindal KK, et al. Clinical practice guidelines for initiation of dialysis (Canadian Society of Nephrology). J Am Soc Nephrol. 1999;10(suppl):S289–S291
  12. Kelly J, Stanley M, Harris D. The CARI Guidelines: Acceptance into Dialysis Guidelines. Nephrology. 2005;10(suppl 4):S46–S60
  13. Obrador GT, Arora P, Kausz AT, et al. Level of renal function at the initiation of dialysis in the U.S. end-stage renal disease population. Kidney Int. 1999;56:2227–2235
  14. Russ GR: ANZDATA Registry Report 2000. Australia and New Zealand Dialysis and Transplant Registry; Woodville, South Australia.
  15. Churchill DN, Taylor DW, Keshiviah PR Canada-USA (CANUSA) peritoneal dialysis study group. Adequacy of dialysis and nutrition in continuous peritoneal dialysis: Association with clinical outcomes. J Am Soc Nephrol. 1996;7:198–207
  16. Kazmi WH, Gilbertson DT, Obrador GT, et al. Effect of co-morbidity on the increased mortality associated with early initiation of dialysis. Am J Kidney Dis. 2005;46:887–896
  17. Beddhu S, Samore M, Roberts M, et al. Impact of timing of initiation of dialysis on mortality. J Am Soc Nephrol. 2003;142:305–312
  18. Levey AS, Bosch JP, Lewis JB, et al. Modification of Diet in Renal Disease Study Group A more accurate method to estimate glomerular filtration rate from serum creatinine: A new prediction equation. Ann Intern Med. 1999;130:461–470
  19. Pollock CA, Ibels LS, Zhu FY, et al. Protein intake in renal disease. J Am Soc Nephrol. 1997;8:777–783
  20. Cooper BA, Aslani A, Ryan M, et al. Nutritional state correlates with renal function at the start of dialysis. Perit Dial Int. 2003;23:291–295
  21. Keshaviah PR, Emmerson PF, Nolph KD. Timely initiation of dialysis: A urea kinetic approach. Am J Kidney Dis. 1999;33:344–348
  22. Mehrotra R, Nolph KD. Treatment of advanced renal failure: Low protein diets or timely initiation of dialysis?. Kidney Int. 2000;28:1381–1388
  23. Jansen MAM, Korevaar JC, Dekker FW, et al. NECOSAD Study Group Renal function and nutritional status at the start of chronic dialysis treatment. J Am Soc Nephrol. 2001;12:157–163
  24. McLaughlin K, Manns B, Donaldson C, et al. An economic evaluation of early versus late referral of patients with progressive renal insufficiency. Am J Kidney Dis. 2001;38:1122–1128
  25. Termorshuizen F, Korevaar JC, Dekker FW, et al. NECOSAD Study Group Time trends in the initiation and dose of dialysis in end-stage renal disease patients in The Netherlands. Nephrol Dial Transplant. 2003;18:552–558
  26. Mehrotra R, Lee J, Elivera H, et al. Trends in initiation of dialysis in an urban dialysis clinic in the United States: A long way from dialysis outcomes quality initiatives. Adv Perit Dial. 1999;15:138–143
  27. Korevaar JC, Jansen MA, Dekker FW, et al. Evaluation of DOQI guidelines: Early start of dialysis treatment is not associated with better health-related quality of life. Am J Kidney Dis. 2002;39:108–115
  28. Seikaly MG, Salhab N, Browne R. Patterns and time of initiation of dialysis in US children. Pediatr Nephrol. 2005;20:982–988
  29. Szeto CC, Lai KN, Wong TY, et al. Independent effects of residual renal function and dialysis adequacy on nutritional status and patient outcome in continuous ambulatory peritoneal dialysis. Am J Kidney Dis. 1999;34:1056–1064
  30. Merkus MP, Jager KJ, Dekker FW, et al. The NECOSAD Study Group Predictors of poor outcome in chronic dialysis patients (The Netherlands Cooperative Study on the Adequacy of Dialysis). Am J Kidney Dis. 2000;35:69–79
  31. Lysaght MJ, Vonesh EF, Gotch F, et al. The influence of dialysis treatment modality on the decline of remaining renal function. ASAIO Trans. 1991;37:598–604
  32. Jansen MA, Hart AA, Korevaar JC, et al. NECOSAD Study Group Predictors of the rate of decline of residual renal function in incident dialysis patients. Kidney Int. 2002;62:1046–1053
  33. Hufnagel G, Michel C, Queffeulou G, et al. The influence of automated peritoneal dialysis on the decrease in residual renal function. Nephrol Dial Transplant. 1999;14:1224–1228
  34. Banli O, Altun H, Oztemel A. Early start of CAPD with the Seldinger technique. Perit Dial Int. 2005;25:556–569
  35. Zaman F, Pervez A, Atray NK, et al. Flouroscopy-assisted placement of peritoneal dialysis catheters by nephrologists. Semin Dial. 2005;18:247–251
  36. Ogunc G. Minilaparoscopic extraperitoneal tunneling with omentopexy: A new technique for CAPD catheter placement. Perit Dial Int. 2005;25:551–555
  37. Heaf JG, Lokkegaard H, Madsen M. Initial survival advantage of peritoneal dialysis relative to haemodialysis. Nephrol Dial Transplant. 2002;17:112–117
  38. Shahab I, Khanna R, Nolph KD. Peritoneal dialysis or hemodialysis? (A dilemma for the nephrologist). Adv Perit Dial. 2006;22:180–185
  39. Burkart JM. Clinical experience: How much earlier should patients really start renal replacement therapy?. J Am Soc Nephrol. 1998;9(suppl 12):S118–S123
  40. Huisman RM. The deadly risk of late referral. Nephrol Dial Transplant. 2004;19:2175–2180
  41. Kessler M, Frimat L, Panescu V, et al. Impact of nephrology referral on early and midterm outcomes in ESRD (EPidemiologie de l’Insuffisance REnale chronique terminale en Lorraine (EPIREL): Results of a 2-year, prospective, community-based study). Am J Kidney Dis. 2003;42:474–485
  42. Winkelmayer WC, Owen W, Levin R, et al. A propensity analysis of late versus early referral and mortality on dialysis. J Am Soc Nephrol. 2003;14:486–492
  43. Lin CL, Chuang FR, Wu CF, et al. Early referral as an independent predictor of clinical outcome in end-stage renal disease on HD and continuous ambulatory peritoneal dialysis: A case control study. Am J Kidney Dis. 1995;25:276–280
  44. Stack AG. Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States. Am J Kidney Dis. 2003;41:310–318
  45. Roderick P, Jones C, Drey N, et al. Late referral for end-stage renal disease: A region-wide survey in the south west of England. Nephrol Dial Transplant. 2002;17:1252–1259
  46. Lin CL, Wu MS, Hsu PY, et al. Improvement of clinical outcome by early nephrology referral in type II diabetic on hemodialysis. Ren Fail. 2003;25:455–464
  47. Bradbury BD, Fissell RB, Albert JM, et al. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am J Nephrol. 2007;2:89–99
  48. Sabath E, Vega O, Correa-Rotter R. Early referral to the nephrologist: Impact on initial hospitalization and the first 6 months of continuous ambulatory peritoneal dialysis. Rev Invest Clin. 2003;55:489–493
  49. Cass A, Cunningham J, Arnold PC, et al. Delayed referral to a nephrologist: Outcomes among patients who survive at least one year on dialysis. Med J Aust. 2002;177:135–138
  50. Cass A, Cunningham J, Snelling P, et al. Late referral to a nephrologist reduces access to renal transplantation. Am J Kidney Dis. 2003;42:1043–1049
  51. Sprangers B, Evenepoel P, Vanrenterghem Y. Late referral of patients with chronic kidney disease: No time to waste. Mayo Clin Proc. 2006;81:1487–1494
  52. Russ GR. 29th Annual Report of the Australian and New Zealand Dialysis and Transplant Registry. 2006;Adelaide, South Australia
  53. Khan SS, Xue JL, Kazmi WH, et al. Does predialysis nephrology care influence patient survival after initiation of dialysis. Kidney Int. 2005;67:1038–1046
  54. Schwenger V, Morath C, Hofmann A, et al. Late referral—a major cause of poor outcome in the very elderly dialysis patient. Nephrol Dial Transplant. 2006;21:962–967
  55. Cass A, Cunningham J, Snelling P, et al. Urban disadvantage and delayed nephrology referral in Australia. Health Place. 2003;9:175–182
  56. Avorn J, Bohn RL, Levy E, et al. In: Nephrologist care and mortality in patients with chronic renal insufficiency. 162:2002;p. 2002–2006
  57. Jander A, Nowicki M, Tkaczyk M, et al. Does a late referral to a nephrologist constitute a problem in children starting renal replacement therapy in Poland? (A nationwide study). Nephrol Dial Transplant. 2006;21:957–961
  58. Obrador GT, Ruthazer R, Arora P, et al. Prevalence of and factors associated with suboptimal care before initiation of dialysis in the United States. J Am Soc Nephrol. 1999;10:1793–1800
  59. Valderrabano F, Horl WH, Macdougall I, et al. Predialysis survey on anaemia management. Nephrol Dial Transplant. 2003;18:89–100
  60. Ravani P, Marinangeli G, Stacchiotti L, et al. Structured pre-dialysis programs: More than just timely referral. J Nephrol. 2003;16:862–869
  61. Lhotta K, Zoebl M, Mayer G, et al. Late referral defined by renal function: Association with morbidity and mortality. J Nephrol. 2003;16:855–861
  62. Dogan E, Erkoc R, Sayarlioglu H, et al. Effects of late referral to a nephrologist in patients with chronic renal failure. Nephrology. 2005;10:516–519
  63. Kinchen KS, Sadler J, Fink N, et al. The timing of specialist evaluation in chronic kidney disease and mortality. Ann Int Med. 2002;137:479–486
  64. Ortega T, Ortega F, Diaz-Corte C, et al. The timely construction of arteriovenous fistulae: A key to reducing morbidity and mortality and to improving cost management. Nephrol Dial Transplant. 2005;20:598–603
  65. Lee W, Campoy S, Smits G, et al. Effectiveness of a chronic kidney disease clinic in achieving K/DOQI guideline targets at initiation of dialysis—a single centre experience. Nephrol Dial Transplant. 2007;22:833–838
  66. Levin A, Lewis M, Mortiboy P, et al. Multidisciplinary predialysis programs: quantification and limitations of their impact on patient outcomes in two Canadian settings. Am J Kidney Dis. 1997;29:533–540
  67. Owen JE, Walker RJ, Edgell L, et al. Implementation of a pre-dialysis clinical pathway for patients with chronic kidney disease. Int J Qual Health Care. 2006;18:145–151

PII: S1548-5595(07)00058-4

doi:10.1053/j.ackd.2007.04.004

Advances in Chronic Kidney Disease
Volume 14, Issue 3 , Pages e27-e34, July 2007

Article Tools