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Am J Kidney Dis. 2005 Nov;46(5):881-6.

Ultralate referral and presentation for renal replacement therapy: socioeconomic implications.

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  • 1Renal Section, Clinical Research Center, Morehouse School of Medicine, Atlanta, GA 30310, USA.



Clinical and metabolic complications of late referral (LR) for dialysis therapy have been well documented, but there is a paucity of data on its socioeconomic implications. This study examines the role of lifestyle and socioeconomic status on referral pattern.


During a 4-year period (1999 to 2002), we retrospectively reviewed records of all patients who initiated dialysis therapy at an urban tertiary-care center. Patients were classified into 3 categories according to the interval between first contact with a nephrologist and initiation of dialysis therapy: contact time of 3 months or longer indicates early referral (ER); 1 to less than 3 months, LR; and less than 1 month, ultralate referral (ULR).


Of 460 patients (97% African Americans, 3% Hispanics), 212 patients (46%) were ULR, 168 patients (37%) were LR, and 80 patients (17%) were ER. Compared with ER and LR patients, those with ULR had significantly (P < 0.0001) lower hematocrits (23% versus 29% and 27%), serum albumin levels (3.1 versus 3.3 and 3.2 g/dL [31 versus 33 and 32 g/L]), and glomerular filtration rates (5 versus 8 and 7 mL/min/1.73 m2 [0.08 versus 0.13 and 0.12 mL/s/1.73 m2]), but greater rates of temporary dialysis catheter use (92% versus 39% and 70%) and mortality (40% versus 15% and 26%, respectively). Logistic regression analysis showed an association between mortality and homelessness (odds ratio, 3.8; P < 0.0001), polysubstance abuse (odds ratio, 2.3; P = 0.013), and alcoholism (odds ratio, 2.2; P = 0.009). Alcoholics (odds ratio, 2.5; P = 0.03), substance abusers (odds ratio, 5.5; P = 0.001), and the homeless/unemployed (odds ratio, 6.0; P = 0.004) were more likely to present as ULR cases. Patient-provided explanations for LR and ULR were denial (45%), unawareness of the presence of chronic kidney disease (30%), and economic difficulties (25%). Denial was more prevalent in LR (52%; P = 0.003) and ULR cases (39%; P = 0.003).


Poor socioeconomic status is a major contributor to delayed referral. More efforts need to be directed at patient and physician chronic kidney disease educational awareness and improved health care access for inner-city and minority populations.

[PubMed - indexed for MEDLINE]
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