Early referral to nephrological care improves long-term survival and hospitalization after dialysis initiation, independent of optimal dialysis start – a call for harmonization of reimbursement policies

Abstract

Early treatment of kidney disease can slow disease progression and reduce the increased risk of mortality associated with end-stage kidney disease. However, uncertainty exists whether early referral (ER) to nephrological care per se or an optimal dialysis start impacts patient outcome after dialysis initiation. We determined the effect of ER and suboptimal dialysis start on the 3-year mortality and hospitalizations after dialysis initiation. Between January 2015 and July 2018, 349 patients with ≥1 month of follow-up started dialysis at nine Romanian dialysis clinics. After excluding patients with COVID-19 during follow-up, 254 patients (97 ER and 157 late referral) were included in this retrospective study. The observational period was truncated at 3 years, death, or loss to follow-up. Clinical and laboratory data were retrieved from the quality database of the nephrological care providers. Patients were followed for a median (25–75%) of 36 (16–36) months. At dialysis start, ER patients had higher hemoglobin, phosphate, and albumin levels and started dialysis less often via a central dialysis catheter (p < 0.001 for each). Logistic regression analysis demonstrated an independent lower risk for frequent hospitalizations for ER patients (odds ratio 0.22 (95% confidence interval 0.1–0.485), p < 0.001), and Cox regression analysis revealed an improved survival (hazard ratio 0.540 (95% confidence interval 0.325–0.899), p = 0.02), both independent of optimal dialysis start. In conclusion, early referral to nephrological care was associated with improved survival and lower hospitalization rates during the three years after dialysis initiation, independent of optimal dialysis start. These results strongly support the reimbursement of nephrological care before dialysis initiation.

Keywords:

• Chronic kidney disease
• mortality
• hospitalization
• dialysis
• early referral

Acknowledgements

We thank Dr. Olivera Stojceva for valuable support and all the patients and staff at the participating dialysis clinics for their collaboration. The study did not receive any specific funding.

Author contributions

L.B., N.P., M.G., and F.M. conceived the study. L.B. and N.P. collected data. M.H., E.S., and C.S. analyzed the data. M.H. and L.B. wrote the manuscript with input from all authors. All authors provided critical feedback, helped shape the research, analysis and manuscript, and approved the final version of the manuscript

Disclosure statement

MH is an advisory board member at Resverlogix, the chairman of the board of the ERA CKD-MBD Working Group, and a member of the Guidelines Committee of the Swedish Society of Nephrology. All authors are employees of Diaverum. No potential conflict of interest was reported by the author(s).

Data availability statement

Data will be made available on reasonable request.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.