Dialysis Therapies Predialysis Nephrologic Care and a Functioning Arteriovenous Fistula at Entry Are Associated With Better Survival in Incident Hemodialysis Patients: An Observational Cohort Study Vı ´ctor Lorenzo, MD, Marisa Martı ´n, MD, Margarita Rufino, MD, Domingo Herna ´ ndez, MD, Armando Torres, MD, and Juan Carlos Ayus, MD ● Background: Late nephrologist referral may adversely affect outcome in patients initiating maintenance hemodi- alysis therapy, mostly with temporary catheters that may further increase morbidity and mortality. Our aim was to evaluate the influence of 2 variables on mortality: presentation mode (planned versus unplanned) and type of access (arteriovenous fistula [AVF] versus temporary catheter) at entry. Methods: This was a 3-center, 5-year, prospective, observational, cohort study of 538 incident patients. Measurements included presentation mode, type of access, renal function and biochemical test results at entry, and stratification of risk groups. Main outcome measures were mortality and hospitalization. Results: Of 281 planned patients (52%), 73% initiated therapy with an AVF. Of 257 unplanned patients (48%), 70% initiated therapy with a catheter (P < 0.001). Multivariate Cox analysis showed that unplanned presentation (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.23 to 2.44) and initiation of therapy with catheter (HR, 1.75; 95% CI, 1.25 to 2.46) were independently associated with greater mortality and similar HRs after adjusting for confounders. At 12 months, the number of deaths was 3 times higher in both the unplanned versus planned groups and catheter versus AVF groups. The joint effect of unplanned dialysis initiation and catheter use had an additive impact on mortality (HR, 2.89; 95% CI, 1.97 to 4.22). Greater hematocrit (HR, 1.04; 95% CI, 1.01 to 1.09) and albumin level (HR, 1.79; 95% CI, 1.37 to 2.33) showed an independent association with survival, underscoring the benefits of predialysis care. Using Poisson regression, all-cause hospitalization (incidence rate ratio, 1.56; 95% CI, 1.36 to 1.79; P < 0.001) and infection-related (incidence rate ratio, 2.62; 95% CI, 1.91 to 3.59; P < 0.001) and vascular access–related (incidence rate ratio, 1.49; 95% CI, 1.15 to 1.94; P < 0.003) admissions were higher in unplanned patients initiating therapy with a catheter than in planned patients initiating therapy with an AVF, after adjusting for confounders. Conclusion: Unplanned dialysis initiation and temporary catheter were independently associated with greater mortality rates in incident patients. The combined influence of both variables was associated with greater morbidity and mortality than either variable alone. Am J Kidney Dis 43:999-1007. © 2004 by the National Kidney Foundation, Inc. INDEX WORDS: Vascular access; predialysis nephrologic care; patient referral; hemodialysis (HD) mortality. T HE INCIDENCE OF treated end-stage re- nal disease (ESRD) in countries with estab- lished dialysis programs continues to increase annually at 6% to 16%, with a corresponding increase in costs. 1 Annual mortality rates in main- tenance hemodialysis (MHD) patients remain high, from 9% in Japan to 16% on average in Europe to 24% in the United States, where only one third of dialyzed patients survive 5 years and mortality of cardiovascular origin is 10 to 20 times greater than in the general population. 1,2 Insufficient care of patients with chronic renal failure before ESRD could be one of the causes of unacceptably high mortality rates in patients on renal replacement therapy. There is increasing evidence that late referral of patients with chronic renal failure to a nephrologist has an adverse effect on morbidity and mortality and consumes considerable health care resources. 3-12 It is esti- mated that 20% to 57% of patients in Europe and the United States are referred very late to a nephrologist. 13,14 In addition to the detrimental effect on health, direct and indirect costs that result from late referral compared with optimal predialysis renal support may represent more than 10% of the annual sum spent on MHD. 15 From the Nephrology Section and Research Unit, Hospi- tal Universitario de Canarias, Fundacio ´n Reina Sofı ´a de Investigacio ´n, Santa Cruz de Tenerife; Nephrology Section, Hospital Arnau de Vilanova, Lleida, Catalonia, Spain; and the Department of Nephrology, University of Texas Health Science Center, San Antonio, TX. Received October 23, 2003; accepted in revised form February 6, 2004. See Appendix for participating members of this study. Supported in part by grant no. FIS 99/0153 from Instituto de Salud Carlos III, Spanish Ministry of Health (V.L.). Address reprint requests to Victor Lorenzo, MD, Servicio de Nefrologı ´a, Hospital Universitario de Canarias, La La- guna 38320, Santa Cruz de Tenerife, Spain. E-mail: lorenzovictor@terra.es © 2004 by the National Kidney Foundation, Inc. 0272-6386/04/4306-0006$30.00/0 doi:10.1053/j.ajkd.2004.02.012 American Journal of Kidney Diseases, Vol 43, No 6 (June), 2004: pp 999-1007 999