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4.2 Preparation for Renal Replacement Therapy (RRT) 4.2.1 Early Referral Patients with renal impairment or significant proteinuria should be referred to a nephrology centre for assessment and to explore the scope for intervention. The Renal Association suggests patients with plasma creatinine above 150 umol/l and/or significant proteinuria (>1g/24hrs) should be referred (ref.25). Because it is increasingly recognised that patients with a creatinine as low as 300 umol/l can have ESRF (see Section 4.2.6) it is important that patients with this degree of impairment or worse are referred urgently. An unplanned start to the initiation of RRT has detrimental consequences for patient outcome (ref.64). Besides the limited time available to attend to medical complications such as anaemia and bone disease and to make preparations for vascular and peritoneal access, lack of education and information may also exert a negative impact on the prognosis. The percentage of patients with ESRF failure who present or are referred to a nephrologist 'late' varies greatly across Europe. Comparisons are difficult because of the different definitions which are employed. However, one survey which defined 'late' as referral within one month of the necessity for dialysis found the percentage ranged from 10 to 51% in 18 facilities across 7 countries (ref.65). In Northern Ireland 34% new RRT patients arrive 'late' without prior referral. (Doherty C - personal communication). There are a number of explanations for the late referral of patients. The evolution of CRF is insidious in the majority, the diagnosis only becoming obvious with the appearance of late uraemic symptoms. This type of late referral can only be avoided by regular screening for renal disease in asymptomatic patients which is costly and of uncertain efficacy. In a smaller group of patients, renal disease is rapidly progressive (e.g. in the context of vasculitis). Late referral may not be avoidable in these circumstances. In other situations the referring physician may not be aware of the severity of the disease or the time needed for adequate pre ESRF care. Some late referrals may in fact be hidden non-referrals. Khan (ref.66) in the UK and Mendelssohn (ref.67) in Canada found that the number of patients with ESRF who are not referred increases with age and co-morbidity. This suggests that some physicians decide that RRT is not appropriate without seeking nephrology advice. A significant proportion of these patients, particularly the elderly, may be referred when their condition deteriorates terminally. In another group of patients ESRF is the consequence of a sudden and unexpected deterioration of pre-existing renal insufficiency. This may be due to iatrogenic diagnostic or therapeutic procedures or prescription of drugs which can upset renal function e.g. non steroidal anti inflammatory drugs (NSAIDs) which are widely prescribed for rheumatic pains. Late referral is a strong determinant of dialysis modality, only a minority of these patients ultimately being established on PD. Most continue to be treated by HD which is usually the initial life saving treatment in late referral. Late referral also has a negative impact on morbidity and mortality in ESRF with a longer duration of hospitalisation at the start of RRT, a lower number of successfully transplanted patients and a higher mortality (ref.68).  |