Early referral and planned initiation of dialysis: what impact on quality of life?

Abstract

Background. Early patient referral correlates with improved patient survival on dialysis. We examine whether early referral and a planned first dialysis affect quality of life (QoL).Methods. All patients commencing dialysis in nine centres in seven European countries between 1 July 1998 and 31 October 1999 were recruited. Definitions: early referral = followed by a nephrologist > 1 month before first dialysis (< 1 month = late referral); planned = early referral and previous serum creatinine > 300 mumol/l and non-urgent first dialysis (early referral and no creatinine > 300 gmol/l or urgent first dialysis = unplanned). QoL was measured at 8 weeks using a visual analogue scale (VAS) and Short Form 36 (SF-36).Results. VAS was significantly higher in early referral patients [mean (SD) 58.4 (20) vs 50.4 (19), P=0.005], particularly if the first dialysis was planned [60.7 (20) vs 54.2 (20), P = 0.03]. Planned patients also had higher SF-36 mental summary scores [45.4 (12) vs 39.7 (11), P = 0.003], role emotional scores [58.0 (43) vs 30.9 (38), P = 0.003], and mental health scores [63.7 (24) vs 54.6 (22), P = 0.01] than unplanned patients. Adjusting for centre and other confounding variables showed that having a planned first dialysis had an independent effect on QoL (VAS, and the SF-36's mental summary score, physical functioning, role physical, general health, role emotional and mental health). Early referral had no independent effect on QoL. Socio-economic status had an important positive effect on physical QoL.Conclusions. While the effect of early referral to a nephrologist on QoL appeared centre dependent, a smooth transition onto dialysis was associated with significantly better early QoL, independent of other variables.Background. Early patient referral correlates with improved patient survival on dialysis. We examine whether early referral and a planned first dialysis affect quality of life (QoL).Methods. All patients commencing dialysis in nine centres in seven European countries between 1 July 1998 and 31 October 1999 were recruited. Definitions: early referral = followed by a nephrologist > 1 month before first dialysis (< 1 month = late referral); planned = early referral and previous serum creatinine > 300 mumol/l and non-urgent first dialysis (early referral and no creatinine > 300 gmol/l or urgent first dialysis = unplanned). QoL was measured at 8 weeks using a visual analogue scale (VAS) and Short Form 36 (SF-36).Results. VAS was significantly higher in early referral patients [mean (SD) 58.4 (20) vs 50.4 (19), P=0.005], particularly if the first dialysis was planned [60.7 (20) vs 54.2 (20), P = 0.03]. Planned patients also had higher SF-36 mental summary scores [45.4 (12) vs 39.7 (11), P = 0.003], role emotional scores [58.0 (43) vs 30.9 (38), P = 0.003], and mental health scores [63.7 (24) vs 54.6 (22), P = 0.01] than unplanned patients. Adjusting for centre and other confounding variables showed that having a planned first dialysis had an independent effect on QoL (VAS, and the SF-36's mental summary score, physical functioning, role physical, general health, role emotional and mental health). Early referral had no independent effect on QoL. Socio-economic status had an important positive effect on physical QoL.Conclusions. While the effect of early referral to a nephrologist on QoL appeared centre dependent, a smooth transition onto dialysis was associated with significantly better early QoL, independent of other variables.