Structured pre-dialysis programs: more than just timely referral?

BACKGROUND

Patients who begin chronic dialysis within 3 months of seeing a nephrologist (late referral)have increased morbidity and mortality. However, it is not known whether formal pre-dialysis education programs (PEPs) are more advantageous, regarding early dialysis outcomes and resource use, than unstructured specialist follow-up.

METHODS

We prospectively collected information on specialist care, unstructured or PEP, modality choice and hospitalizations in the 1st 3 months of dialysis for all consecutive patients who started dialysis between 1st January 1999 and 30th June 2002 in two Italian centers.

RESULTS

The 229 patients who participated in this study (62% male, median age 70 yrs) had a high prevalence of diabetes (27.5%) and cardiovascular disease (60%). Of these, 22.7% received unstructured follow-up and 40.6% received PEP care. Peritoneal dialysis (PD) was the first choice modality for 41.5% of patients and 55% had a planned start. Excluding late referrals (36.7%), the likelihood of PD selection was similar between PEP and unstructured care (52.7% vs. 40.4%, p = NS), while that of a planned start was greater among PEP patients (91.4% vs. 38.5%, p < 0.001). Multivariate analysis showed that only PEP (but not unstructured care) vs. late referral had a significant association with reduced odds of hemodialysis (HD) selection (OR: 0.301, [95%CI 0.153, 0.594]), emergency start (0.031 [0.013, 0.075]), 1st hospitalization > 5 days (0.165 [0.081, 0.333]), and further hospitalizations (0.346 [0.174, 0.685]). Late referrals independently predicted the lack of modality selection (1.847 [1.007, 3.388]).

CONCLUSIONS

A structured PEP seemed to improve early dialysis outcomes and resource usage beyond that gained by a timely referral, except for the opportunity to select modality.