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PubMed2004

Nephrology nursing: blurring the boundaries: the reality of expert practice.

BACKGROUND: Expertise in nursing has been widely studied; there have been no previous studies into what constitute expertise in nephrology (renal) nursing. This paper describes a 'real-world' characteristic of expert nephrology nursing practice. AIMS AND OBJECTIVES: This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the concept blurring the boundaries. DESIGN: The study utilized grounded theory methodology and symbolic interactionism. METHODS: The study took place in one renal unit in New South Wales. Sampling was purposive then theoretical; the sample consisting of six non-expert and eleven expert nurses. Simultaneous data collection and analysis using participant observation, review of nursing documentation and semi-structured interviews was undertaken. RESULTS: The study revealed that only expert nephrology nurses 'blurred the boundaries' of professional nursing practice. They did this by moving intermittently and purposefully, for the benefit of particular patients, into medical domains in the areas of prescribing, dispensing and ordering of pathology tests. Non-expert nurses did not cross these professional boundaries. CONCLUSIONS: Blurring the boundaries was a significant feature of expert nursing practice, and this study was the first to describe explicitly nursing boundaries as two distinct entities; that is, formal and informal. RELEVANCE TO CLINICAL PRACTICE: There are some nephrology nurses who have sufficient knowledge and experience to prescribe some medications and to order certain investigations.

Attitude of Health Personnel↗
PubMed2002

Nephrology, dialysis and transplantation in Turkey.

The establishment of the Turkish Society of Nephrology (TSN) in 1970 coincided with that of many western European nephrology societies. The TSN organized the 15th ERA-EDTA Congress in Istanbul in 1978, earlier than many European Countries, and currently has 286 active members. At present, Turkey has 161 nephrologists, which equals 2.5 nephrologists per million population (p.m.p.). The number of original articles submitted by Turkish authors to the journal Nephrology Dialysis Transplantation ranks 7th-8th amongst total submissions to the journal. Turkey also ranks 2nd-4th in the number of abstracts submitted to recent ERA-EDTA Congresses. With 18 063 patients undergoing intermittent haemodialysis treatment in 348 dialysis centres, Turkey has the 5th largest chronic haemodialysis patient population among European countries. In addition, 1903 patients are currently undergoing continuous ambulatory peritoneal dialysis. However, with a total of 4693 renal transplants since 1975, of which only 21.3% were of cadaveric origin, Turkey lags considerably behind other European countries in renal transplantation. In Turkey, the prevalence and incidence of renal replacement therapy (RRT) are at present 358 and 52 p.m.p. respectively, and the expansion rate of the RRT stock is 17% (HD 18.5%, CAPD 6%, and transplantation 1.7%). The yearly gross mortality rate of the total RRT population is 9.4%. The present priorities of the Turkish nephrological community include high-standard research activity and long-term, prospective clinical and epidemiological studies, an increase in the total number and percentage of cadaveric transplants, further improvement of the quality and cost-effectiveness of RRT, and finally the further development of scientific and educational collaboration with the world nephrological community.

Health Care Costs↗
PubMed2006

Uncovering the evidence of non-expert nephrology nursing practice.

Expertise in nursing has been widely studied although there have been no previous studies into what constitutes expertise in nephrology (renal) nursing. This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, provides evidence of the characteristics and practices of non-expert nephrology nurses. Using the grounded theory method, the study took place in one renal unit in New South Wales, Australia, and involved six non-expert and 11 expert nurses. Sampling was purposive then theoretical. Simultaneous data collection and analysis using participant observation, review of nursing documentation and semistructured interviews was undertaken. The study revealed a three-stage skills-acquisitive process that was identified as non-expert, experienced non-expert and expert stages. Non-expert nurses showed superficial nephrology nursing knowledge and limited experience; they were acquiring basic nephrology nursing skills and possessed a narrow focus of practice.

Attitude of Health Personnel↗
PubMedDate not supplied

Establishing nephrology nursing specialization in Japan: a matter of urgency.

This paper explores the current situation regarding the provision of renal services to patients with end-stage renal disease in Japan. The statistical data reveal that Japan is in a predicament regarding the current rate of incidence of end-stage renal disease in the population. The discussion highlights the fact that nephrology nursing practice is as yet not recognised as a speciality in its own right in Japan. Therefore Japanese nurses who work in the field of nephrology are still struggling to establish their own professional identity and to improve the professional level of their practice. This situation persists in Japan despite support from the literature, which confirms that appropriately qualified nephrology nurses are well equipped to provide specialised care. The recent decision by the Japanese Association of Nephrology Nurses is to establish the position of the specialised dialysis nurse, which does not cover the area of kidney transplantation and will start in 2004. It is expected that it will be an important challenge to improve professional skills and nephrology nursing status in Japan.

Health Services Needs and Demand↗
PubMed2005

Challenges in interventional nephrology.

Lately, there has been a progressive decrease in the interest of nephrology as a medical sub-specialty reflected primarily in the decreasing number of renal fellows. Rising costs in establishing and running dialysis clinics and the lost of nephrologic procedures previously performed by nephrologists are among the many reasons for this disillusionment with the specialty. The care of chronic kidney patients frequently involve many diagnostic and interventional radiological procedures such as: diagnostic renal ultrasonography, ultrasound-guided kidney biopsies, placement of tunneled hemodialysis catheters or peritoneal catheters, sonographic and radiological investigation of vascular access dysfunction, etc. Most of these procedures are nowadays performed by radiologists, vascular surgeons and surgeons in general. This fragmentation does not optimize medical care and it is inconvenient to the patient. This has led many nephrologists to introduce a new paradigm in kidney patients management, often referred as interventional nephrology (IN). This new breed of nephrologists have acquired diagnostic and interventional skills for procedures usually done by others with an added clinical perspective. To train nephrologists in these procedures and avoid the fragmented care of renal patients, the American Society for Diagnostic and Interventional Nephrology was established in 2000 and the International Society of Nephrology in 2004 introduced a new committee to address the issues of IN. It is hoped that concerted efforts will help to rescue these activities for the nephrologists and improve quality of patient care.

Humans↗
PubMedDate not supplied

Biochemical and microscopic urinalysis: time and cost in a nephrology laboratory.

BACKGROUND: Urinalysis is a fundamental test in internal medicine and nephrology. Figures for costs are available in the general laboratory, where biochemical and microscopic urinalysis are commonly performed as semiautomated screening tests. Information on costs is lacking in the nephrology laboratory, where a time-consuming morphological analysis is usually preferred. This study analyses the costs of urinalysis in a nephrology laboratory. METHODS: In the nephrology laboratory at the University of Turin - Italy, biochemical urinalysis consists of multi-property strip and proteinuria/creatininuria, done by laboratory technicians. Phase-contrast microscopy is done by a nephrologist or biologist. Time dedicated to the tests was recorded by the same operator over 20 working days, during which 350 urine samples were processed (median 19/day, range 842). The production costs were calculated with the logic bottom-up technique. RESULTS: Overall time needed was 11.9 minutes/sample. Biochemical urinalysis required 6.6 minutes/sample; time required and samples processed were inversely related (< or =19 samples: 7.95 minutes/sample; >19 samples: 5.6 minutes/sample, p=0.01). Microscopic urinalysis took 5.3 minutes/slide; the best time-to-samples ratio was at 18-22 samples per day (with peak efficiency at 21 samples: 4.6 minutes). Cost of reagents and disposables was Euro1.06/sample. Time accounted for euro 5.32/sample (technicians, nephrologist-biologist), with total direct cost of euro 6.38/sample. CONCLUSION: In a nephrology laboratory, microscopic urinalysis is a time-consuming, expensive test. Analysis of cost and modalities may be useful, in a time of budget constrains, to maintain a role for this precious semeiotic art.

Chemistry, Clinical↗
PubMedDate not supplied

[Evidence-based guidelines in nephrology].

INTRODUCTION: The preparation of evidence-based guidelines by the Nephrology Societies is fundamental to improve long-term outcomes of patients with chronic kidney diseases. However, this is a complex process and requires the interaction of clinicians and experts in epidemiology methods, and researchers and research enterprises. METHODS: In this review, we present the potential structure of a body for the coordination and development of evidence-based guidelines in a nephrology society and we address the major problems that can arise in this process describing strategies that could be used to overcome them. RESULTS: The development of evidence-based nephrology guidelines requires a structure; this should consist of a coordinating center and a number of working groups. The working groups is to identify specific research questions and to develop and synthetize the evidence in answer to the questions proposed. This shall be done in collaboration with the coordinating center. Draft guidelines produced by this process should be peer reviewed, disseminated and implemented. CONCLUSIONS: The development of evidence-based nephrology guidelines is a challenge for individual nephrology societies. These guidelines are different from typical research publications in that their success does not lie in the final publication, but in the actual dissemination and implementation, which is in the improvement of patient outcomes and its measurement.

Evidence-Based Medicine↗
PubMed2005

Invasive and innovative nephrology.

BACKGROUND: A nephrologist in the millennium offers comprehensive care to renal failure patients. Interventional nephrology plays a major role in this new approach. Overton Brooks Veterans Affairs Medical Center (OBVAMC) is the first federal health care provider in the nation offering such services. Lack of interventional radiologists and a busy surgical service has catalyzed the existence of interventional nephrology at this center. We report our early experience in successfully providing complete care to veterans with renal failure, despite multiple logistical obstacles. METHOD: The OBVAMC is an acute care facility providing nephrology support to hospitalized veterans and also handles access-related issues for eligible chronic dialysis patients. All procedures performed from June 2000 to September 2003 were analyzed. The procedures were performed in the cardiac catheterization laboratory or in the surgical operating rooms. RESULTS: A total of 366 procedures were performed, which included: 110 tunneled cuffed catheter (TCC) placements, 157 temporary dual lumen catheters, 36 TCC removals, 30 fistulograms, 24 thrombectomy-/angioplasty, 1 stent placement, 3 Tenckhoff catheter placements, 3 central venograms, and 2 accessory vein ligations. Bleeding from the exit site of a TCC in one patient was the only complication encountered. CONCLUSION: Interventional nephrology experience at OBVAMC has been very encouraging and has succeeded in providing optimal care to the veterans. Interventional nephrology programs can be developed in any tertiary care hospital.

Humans↗
PubMedDate not supplied

[Census of the Italian Nephrology and Dialysis Units. Comparison between Lombardy and Piedmont].

The Italian Society of Nephrology promoted a national survey to obtain detailed information from all the Renal and/or Dialysis Units through an on-line questionnaire concerning structural, technological and human resources, as well as organisation characteristics and activities. The purpose of this initiative was to obtain regional reference benchmarks for each Nephrology Unit. In this paper we compare two northwestern Italian Regions: Lombardy and Piedmont. As far as epidemiology is concerned, the prevalence of dialysis patients is quite similar in the two Regions: for haemodialysis 616 pmp (patients per million population) in Lombardy and 595 in Piedmont, for peritoneal dialysis 104 pmp vs. 114 pmp, while the incidence of dialysis patients is 169 vs. 166 pmp. The gross mortality for dialysis patients is 12.4% vs. 13.7% and 0.9% vs. 2.0% in transplanted patients. The distribution of vascular access is also quite similar in the two Regions: prevalent arteriovenous fistula 83% vs. 74%, central venous catheter 11% vs. 18%, vascular grafts 7% vs. 8%. Structural resources: the hospital beds (49 pmp in the two Regions) and the dialysis places (161 vs. 166 pmp) do not differ between the two Regions. Personnel resources: physicians 37 pmp in Lombardy and 44 pmp in Piedmont, renal nurses 167 pmp vs. 186, respectively. Activity: hospital admission 1722 pmp vs. 1507 pmp, renal biopsies 131 pmp vs. 109 pmp. Although the two regions examined are numerically different, both have a high standard of quality, making Italy a model of nephrology organisation. This initiative to take a census of the Italian Nephrology and Dialysis Units provides an interesting tool to describe the present status of the operational structures, to identify precise benchmarking values, at both the regional and national level, and to act as a prelude for further rationalization and growth of the nephrology network in Italy.

Ambulatory Care Facilities↗
PubMedDate not supplied

Contribution of Central and Eastern Europe (CEE) to Nephrology.

The Central and Eastern European (CEE) region now consisting of 19 countries with a total population of more than 400 million. From ancient times to recent years the history of this area has been tempestuous with often changing borders, loss of independence and its eventual recovery even after many years. Despite such a complicated history in this region some excellent physicians and scientists were able to establish the basis of modern nephrology. This paper records the development of clinical nephrology and renal replacement therapy in CEE region. Data from 9 countries (Bulgaria, Byelorussia, Croatia, Czech Republic, Hungary, Lithuania, Romania, Serbia and Montenegro and Slovakia) was collected. Mentioned are internationally recognized early nephrologists like: Karl Rokitansky (1804-1878) -- Czech origin, famous pathologist; Sergey Zimnicki (1873-1927) -- Byelorussian physician, founder of the urine concentration test; Sandor Korany (1866-1944) -- Hungarian scientist who described hyposthenuria in chronic renal failure; Stefan Rozenak -- Hungarian working on PD problems, or Emerich Ullmann (1866-1897) - Hungarian, one of the pioneers of transplantation. During more recent years other clinicians working in the region (eg. Jan Brod (1912-1985) -- Czech nephrologist) developed clinical nephrology and renal replacement therapy in the region. Nowadays in all countries mentioned, strong nephrological centers connected with University Hospitals are present and many new ones are coming into existence in regional and local hospitals. Renal replacement therapy was generally underdeveloped for many years, but after political and economical liberation real progress was achieved in this matter in most of the countries. Nephrologists from CEE region, especially from Czech Republic and Hungary, have been very ac-tive organizing many international meetings (ISN, EDTA, ESAO, EDTNA etc) and some of them participate in the boards and councils of these organizations. Summarizing this overview one has to conclude that CEE countries have participated actively in the progress of the modern nephrology, especially during the last century. (On behalf of the CEE group).

Europe↗
PubMed1995

Characteristics of nephrology nurse researchers and their research.

OBJECTIVES: To identify the characteristics of nurses who are conducting research related to renal disease and the care of nephrology patients and to describe the investigations these researchers have conducted. DESIGN: Mailed survey using an investigator-adapted questionnaire, "ANNA Survey of Nephrology Nurse Researchers." SAMPLE/SETTING: Survey mailed to all 1991 members of ANNA's Research Special Interest Group and distributed via mail or at a nursing research conference to other nurses who were known to have conducted nephrology research. Ninety-six of the approximately 400 questionnaires that were distributed were returned; respondents described 147 research projects/programs of study. METHODS: Data were analyzed using descriptive statistics and chi-square analysis. RESULTS: Most respondents were master's prepared nurses who had completed one research study. Adults were the subjects in the majority of studies, and psychosocial phenomena and quality of life were the most frequently identified study foci. Descriptive and comparative studies were more common than experimental investigations. CONCLUSIONS: The findings indicate beginning exploration of a variety of patient care and administrative problems by nephrology nurses. Notably absent, however, was research on topics that present challenges to practicing nephrology nurses, including symptom management, care of diabetic and elderly renal patients, ethical issues, and cardiovascular complications of renal disease. Additional experimental research is needed, particularly to test nursing interventions aimed at alleviating common problems experienced by renal patients.

Humans↗
PubMedDate not supplied

Perspective of a pediatric nephrology program: an 18 year retrospective.

We analyzed the patient profile in a pediatric nephrology training program, along with data collected over an 18 year period, to determine whether there is merit in the proposition that clinical training can be obtained equally well in internal medicine nephrology training programs. We also compared the rate of patient referral in an U.S. metropolitan area with a population of 1.2 million, in the first 9 years without the "gatekeeper" health insurance system and the next 9 years with managed care competition. Finally, we discussed guidelines for renal biopsy in the child and approaches to treatment as practiced in a pediatric nephrology program of almost two decades. We used the same NIH clinical data form throughout the 18 years of data collection to record clinical, laboratory and biopsy diagnosis, dialysis/ transplantation and other treatment data of patients entering our outpatient and inpatient services. Between 1977 and 1996, 3,150 new patients were examined for disorders related to the kidney. Twenty-one per cent of the patients were in the first year of life and 50% were younger than seven years of age. The majority of the 389 percutaneous renal biopsies were done in children under 10 years of age. In addition, almost half of the 112 pediatric dialysis/transplant patients presented before 10 years of age. Thus, the majority of patients were in the early years of life, with an unique pattern of renal diseases and issues regarding therapy which are clearly different from adulthood. Therefore we concluded that the existing data did not support the proposition that pediatric nephrology training be absorbed into internal medicine nephrology programs. The introduction of managed care competition did not affect the rate of patient enrollment. In fact, the rate of referrals in the latter 9 years paralleled the first 9 years. The factors which contribute to this outcome are discussed. Such data should be useful to those trying to meet the challenges of this competitive era. Finally, we discussed guidelines for renal biopsies in children and approaches to specific diseases.

Adolescent↗
PubMed1998

Nephrology nurses' perceptions of barriers and facilitators to using research in practice.

OBJECTIVE: The purpose of this study was to determine nephrology nurses' perceptions of barriers to research utilization and to identify effective ways to facilitate integration of research findings in nephrology nurses' practice. DESIGN: This was an explorative, descriptive study. SAMPLE/SETTING: Four hundred ninety-eight nephrology nurses participated in the study. The primary areas of clinical practice were hemodialysis (36%), peritoneal dialysis (29%), transplantation (15%), pediatric nephrology (3%), or various combinations (18%). METHODS: Participants completed a demographic data form and the previously validated instrument, Barriers and Facilitators to Using Research in Practice. Descriptive statistics were used to analyze the data. RESULTS: The majority of respondents (52%) were staff nurses. The other respondents included 30% in management, 12% in advanced practice roles, and 6% in education. The barriers to research utilization most frequently identified were insufficient time on the job to implement new ideas and not enough time to read research. The most effective facilitators identified were increased administrative support and encouragement, increased time available for reviewing and implementing research findings, and improved understandability of research reports. CONCLUSIONS: Additional nursing and nonnursing administrative support for research activities and designated time to read research and implement research-based clinical practices may facilitate the development of research-based nephrology nursing practice.

Adult↗
PubMed2004

Late nephrology referral and mortality among patients with end-stage renal disease: a propensity score analysis.

BACKGROUND: Late nephrology referral has been associated with adverse outcomes among patients with end-stage renal disease; however, its relationship to mortality is unclear. We examined the impact of timing of nephrology care relative to initiation of dialysis on mortality after initiation of dialysis. METHODS: Data from the Dialysis Morbidity and Mortality Study - Wave II, a prospective study of incident dialysis patients, were used. Late referral (LR) was defined as first nephrology visit <4 months and early referral (ER) as first nephrology visit >or=4 months prior to initiation of dialysis. Propensity scores (PS) were estimated using logistic regression to predict the probability that a given patient was LR. A Cox proportional hazards model was built to examine the association between timing of nephrology referral and mortality. RESULTS: The cohort was comprised of 2195 patients: 54% were males, 66% were Caucasians, 26% were African-Americans and 33% were referred late. A Cox proportional hazards analysis demonstrated that compared with ER patients, LR patients had a 44% higher risk of death at 1 year after initiation of dialysis [hazards ratio (HR) = 1.44; 95% confidence interval (CI): 1.15-1.80], which remained significant after adjusting for quintiles of PS (HR = 1.42; 95% CI: 1.12-1.80). CONCLUSIONS: Among patients with chronic kidney disease (CKD) who initiated dialysis, LR was associated with higher risk of death at 1 year after initiation of dialysis compared with ER.

Female↗
PubMed2006

Screening for depression in chronic hemodialysis patients: comparison of the Beck Depression Inventory, primary nurse, and nephrology team.

Depression in patients with end-state renal disease (ESRD) is both underdiagnosed and treated, which may contribute to an increase in morbidity and mortality. Efforts aimed at screening, diagnosing, and treating depression could potentially modify outcomes in this population. The purpose of this study was to compare the prevalence of depression, as measured by the Beck Depression Inventory (BDI-II), the primary nurse, and nephrology team, among a cohort of patients receiving chronic hemodialysis (HD). A secondary objective was to identify patient variables associated with depression. Patients were screened for depression at the same time point, using the BDI-II, the primary nurse and the nephrology team. Depression was defined as a BDI-II score > or =14. Agreement between the BDI-II score, nurse, and nephrology team assessment of depression was compared using a kappa score and receiver-operating characteristic (ROC) curves were generated. One hundred and twenty-four of an eligible 154 patients completed the study. Depression as measured by a BDI-II> or =14, the nurse and the team was diagnosed in 38.7%, 41.9%, and 24.2% of patients, respectively. With the BDI-II as the gold standard, the nurses' diagnosis of depression had an agreement of 74.6% vs. only 24.2% agreement with the nephrology team. A previous history of malignancy was the only variable associated with the diagnosis of depression. Depression is common among patients on HD, supporting the need for a routine depression-screening program. The primary dialysis nurse is in a key position to identify patients with depression and should be considered as an integral part of the nephrology team.

Adult↗
PubMedDate not supplied

Substance use among Iranian nephrologic patients.

AIMS: This study assessed the prevalence of substance use among Iranian patients with nephrologic disease (chronic renal failure) who were admitted in different nephrologic wards at Shiraz general hospitals. DESIGN: Cross-sectional survey using structured interview and also using DSM-IV criteria for substance dependency. SETTING: General hospitals in Shiraz city (patients with nephrologic disease admitted in different nephrologic wards). PARTICIPANTS: 64 (32 men and 32 women) patients selected randomly. FINDINGS: Data were gathered by a structured interview from 64 patients admitted in nephrologic wards of general hospitals in 2001. The mean age was 49.39 years (SD = 19.62) ranging from 18 to 80 years. 26 (40.6%) of the subjects (65.6% of the men and 15.6% of the women) reported the use of substance(s) once or more in their lives. The majority, 23 (35.9%) used tobacco, 9 (14.1%) used opium and 2 (3.1%) used alcohol. None had used cannabis, heroin, cocaine or LSD. 20 (31.3%) of the subjects (50% of the men and 12.5% of the women) were currently substance dependent, using DSM-IV criteria. The majority, 18 (28.1%) were nicotine dependent, and 6 (9.4%) were opium dependent. There was a nonsignificant relationship between income or occupation or education and prevalence of substance use. The reported reasons for initial use of substance(s), in order of frequency, were enjoyment, modeling and release of tension, and also for current users were, habit, enjoyment and need. CONCLUSIONS: Substance use especially cigarettes, opium and alcohol was found to be high among patients. There was no report of cannabis, heroin, cocaine or LSD use. Cultural attitudes toward substance use were found to affect the type and amount of use. These findings can be considered when planning preventive or therapeutic programs.

Adolescent↗
PubMed1997

[Benefits of early nephrological management in chronic renal failure].

OBJECTIVES: We evaluated whether early nephrological referral of patients with chronic renal failure (CRF) resulted in improved condition of patients at initiation of maintenance dialysis and in better outcome on dialysis. PATIENTS AND METHODS: We prospectively recorded clinical status, laboratory parameters, length of hospital stay and outcome of 900 CRF patients who started maintenance dialysis at Necker hospital between January 1989 and December 1996. We compared patients who benefited regular nephrological follow-up, and patients who were referred in emergency conditions at the ultimate stage of CRF. RESULTS: Among the 900 patients, 731 (81.2%) had regular nephrological follow-up, including 632 (70.2%, group IA) with optimal preparation to dialysis and 99 (11%, group IB) whose clinical course was complicated due to heavy comorbidity, whereas 169 (18.8%, group II) had no previous nephrological management. Over the 8-year observation period, the proportion of the latter group did not decrease. Late referred patients had higher blood pressure level, more frequent fluid overload, higher serum levels of urea, creatinine, uric acid and phosphate, and lower levels of bicarbonate, calcium, albumin and creatinine clearance that did well-prepared patients. Mean (+/- SD) hospital stay was 29.7 +/- 15.8 days in the former compared to only 4.8 +/- 3.3 days (p < 0.001) in the latter. Early deaths within 3 months of dialysis initiation were more frequent (7.1 vs 1.6%, p < 0.05) and less patients subsequently were able to be treated out-center (20.1 vs 40.7%, p < 0.05) in group II than in group IA. The overcost induced by late referral may be estimated at 0.25 million French francs per patient. CONCLUSION: An unjustified late nephrological referral of CRF patients still is observed in nearly 20% of cases. Such late referral is detrimental to both patients in terms of altered quality of life and long hospital stay, and to the collectivity due to heavy overcost. Closer cooperation between family physicians and nephrologists is needed to provide optimal management and allow timely preparation to maintenance dialysis of CRF patients.

Female↗
PubMed1997

[Benefits of early nephrological management of chronic renal failure].

OBJECTIVES: We evaluated whether early nephrological referral of patients with chronic renal failure (CRF) resulted in improved condition of patients at initiation of maintenance dialysis and in better outcome on dialysis. PATIENTS AND METHODS: We prospectively recorded clinical status, laboratory parameters, length of hospital stay and outcome of 900 CRF patients who started maintenance dialysis at Necker hospital between January 1989 and December 1996. We compared patients who benefited regular nephrological follow-up, and patients who were referred in emergency conditions at the ultimate stage of CRF. RESULTS: Among the 900 patients, 731 (81.2%) had regular nephrological follow-up, including 632 (70.2%, group IA) with optimal preparation to dialysis and 99 (11%, group IB) whose clinical course was complicated due to heavy comorbidity, whereas 169 (18.8%, group II) had no previous nephrological management. Over the 8-year observation period, the proportion of the latter group did not decrease. Late referred patients had higher blood pressure level, more frequent fluid overload, higher serum levels of urea, creatinine, uric acid and phosphate, and lower levels of bicarbonate, calcium, albumin and creatinine clearance that did well-prepared patients. Mean (+/- SD) hospital stay was 29.7 +/- 15.8 days in the former compared to only 4.8 +/- 3.3 days (p < 0.001) in the latter. Early deaths within 3 months of dialysis initiation were more frequent (7.1 vs 1.6% p < 0.05) and less patients subsequently were able to be treated out-center (20.1 vs 40.7%, p < 0.05) in group II than in group IA. The overcost induced by late referral may be estimated at 0.25 million French francs per patient. CONCLUSION: An unjustified late nephrological referral of CRF patients still is observed in nearly 20% of cases. Such late referral is detrimental to both patients in terms of altered quality of life and long hospital stay, and to the collectivity due to heavy overcost. Closer cooperation between family physicians and nephrologists is needed to provide optimal management and allow timely preparation to maintenance dialysis of CRF patients.

Female↗