35 In a retrospective review of patients commencing dialysis in a metropolitan New York hospital, Ifudu et al. in 1996 reviewed the outcomes of 139 patients who had been commenced on dialysis between January 1990 and December 1994. Patients were stratified according to whether they had received predialysis care from a nephrologist (43% of cohort) or a non-nephrologist physician (45%) or had received no predialysis medical care (12%).36 Patients who had a period of predialysis care by a nephrologist had a significantly reduced need for emergency central venous access (36% vs 69% vs 100%, nephrologist check details vs non-nephrologist vs no care, P = 0.0001) and reduced

length of hospital stay for the initiation of dialysis (12 ± 23 days vs 25 ± 21 vs 29 ± 23 days, respectively, P = 0.002). Patients who had received predialysis care from a nephrologist were characterized by a lower mean serum creatinine and less severe acidosis than the other two groups at the time of commencement of dialysis. Abdulkader et al. looked

at risk factors for hospital death of patients with CKD who were first reviewed by a nephrologist as an emergency in-hospital referral.37 A total of 414 patients were seen in a tertiary hospital in São Paolo in Brazil. Mortality was 13%. Non-survivors were older, required ventilation and inotropic support, had a higher rate of infection and had a lower creatinine (attributed to malnutrition). Avorn et al. identified 3014 patients who started dialysis in a 6-year period and who were known to have renal

disease more than 12 months learn more prior to commencement.38 There was a 37% increased mortality rate at 1 year in those who had not seen a nephrologist until 90 days or less before starting dialysis. Similarly, those who saw a nephrologist 5 times or less in the 12 months preceding dialysis had a 15% higher mortality rate than those seen more than 5 times. Avorn et al., in a similar cohort of 2398 patients with a diagnosis of renal disease at least 1 year before initiation of dialysis, showed that those who had seen a nephrologist more than Thalidomide 90 days prior to starting dialysis were 38% more likely to have undergone predialysis access surgery (OR 1.38, 95% CI: 1.15–1.64).39 Late referral patients were more likely to start dialysis with temporary vascular access (OR 1.42, 95% CI: 1.17–1.71). Cass et al., in an Australian study using ANZDATA, showed that late referral (<3 months) reduces access to transplantation.40 A total of 3310 patients were studied, of whom 892 were referred late. These patients had more comorbidities and were more likely to have diabetic nephropathy. Adjusting for variables including age and comorbid conditions, they had an OR of listing on the transplant list of 0.49 (95% CI: 0.41–0.59) and were less likely to receive a transplant (HR 0.65, 95% CI: 0.55–0.77).