Referral pattern to nephrologist and prognosis in diabetic kidney disease patients: Single center retrospective cohort study.

BACKGROUND: Management of diabetic kidney disease (DKD) to prevent end-stage kidney disease (ESKD) has become a major challenge for health care professionals. This study aims to investigate the characteristics of patients with DKD when they are first referred to a nephrologist and the subsequent prognoses. METHODS: A total of 307 patients who were referred to our department from October 2010 to September 2014 at Osaka General Medical Center were analyzed. Independent risk factors associated with renal replacement therapy (RRT) and cardiovascular composite events (CVE) following their nephrology referral were later identified using Cox proportional hazards analysis. RESULTS: Of 307 patients, 26 (8.5%), 67 (21.8%), 134 (43.6%), and 80 (26.1%) patients were categorized as having chronic kidney disease (CKD) stages 3a, 3b, 4, and 5, respectively. The median estimated glomerular filtration rate (eGFR) and urinary protein levels were 22.3 mL/min/1.73 m2 and 2.83 g/gCr, respectively, at the time of the nephrology referral. During the follow-up period (median, 30 months), 121 patients required RRT, and more than half of the patients with CKD stages 5 and 4 reached ESKD within 60 months following their nephrology referral; 30% and <10% of the patients with CKD stages 3b and 3a, respectively, required RRT within 60 months following their nephrology referral. CONCLUSION: Patients with DKD were referred to nephrologist at CKD stage 4. Although almost half of the patients with CKD stage 5 at the time of nephrology referral required RRT within one-and-a-half years after the referral, kidney function of patients who were referred to nephrologist at CKD stage 3 and 4 were well preserved.

Duration of predialysis nephrological care and mortality after dialysis initiation.

BACKGROUND: The duration of predialysis nephrological care that can reduce all-cause and cardiovascular mortality after dialysis initiation has not been clarified. METHODS: A total of 1117 patients who started chronic dialysis treatment from 2006 to 2015 at Osaka General Medical Center were analyzed. Independent risk factors associated with all-cause and cardiovascular mortality after dialysis initiation and early death (death within 12 months after dialysis initiation) were identified using Cox proportional hazards analysis. Moreover, the duration of predialysis nephrology care that could reduce mortality was explored using several different definitions of early referral as well as "6 months" commonly used in previous studies. RESULTS: Of 1117 patients, 834 were referred 6 months before dialysis initiation. During the follow-up period (median, 34 months), 324 patients died after dialysis initiation. Although multivariate Cox analysis did not show a favorable association between early referral of "6 months before dialysis initiation" and all-cause and cardiovascular mortality, 20-month predialysis nephrological care was associated with better first-year overall survival after dialysis initiation (hazard ratio 0.58; 95% confidence interval 0.35-0.98; P = 0.040). CONCLUSION: More than 6 months nephrological care before dialysis initiation was not early enough to reduce all-cause and cardiovascular mortality after dialysis initiation. Our results suggest that nephrology referral 20 months before dialysis initiation would be necessary to reduce first-year overall survival after dialysis initiation.