[Effect of an ambulatory program devoted to chronic renal insufficiency on the reduction of mobidity and hospitalization among patients at the beginning of dialysis treatment].

BACKGROUND: Late nephrological referral of end-stage renal disease (ESRD) patients is associated with increased risk of emergent dialysis start and poor complications control. However, the relative contribution of pre-dialysis care organization is unknown.

METHODS: All 175 consecutive patients who started chronic dialysis for ESRD at our Institution from 1.1.99 to 30.6.02 were grouped as follows: referred ? 3 months before dialysis, (A, n=50); followed by non-dedicated specialists (B, n=74) or by pre-dialysis educational program personnel (PEP, n=51). We examined the first six months of hospitalization, uraemic complications control, type of dialysis initiation, and first dialysis modality.

RESULTS: There was no difference in baseline characteristics and comorbidities among groups. PEP patients had higher creatinine clearance, haemoglobin, calcemia and BMI at initiation. They also made greater use of ACE-inhibitors and were more likely to have a planned start and choose peritoneal dialysis. Emergent starts were 50% (A 100%, B 45%, PEP 4%, p<0.001). Mean pre-dialysis hospitalization (due to in-patient emergency dialysis onset for unplanned starts and planned for access insertion for elective out-patient starts) was shorter among PEP patients (7days-PEP, 17days-B, 30days-A). Logistic regression confirmed the predictive role of PEP for emergent start (AOR 0.03, 0.001 to 0.101, p<0.001) even excluding late referrals (AOR 0.1, 0.033 to 0.306, p<0.001), independently of baseline characteristics and comorbidities.

CONCLUSIONS: Pre-dialysis follow-up by dedicated personnel was more effective than traditional specialist care in reducing morbidity and health care resources utilization in patients starting dialysis.