Specialist Evaluation in Chronic Kidney Disease: Too Little, Too Late

Maintenance of patients with end-stage renal disease (ESRD) on long-term dialysis is a triumph of modern medicine. In the United States alone, more than 250 000 persons with ESRD, who otherwise would have died, enjoy life—usually of good quality—because of the availability of hemodialysis and peritoneal dialysis. Yet this triumph has a tragic flaw: The lifespan of dialysis patients remains abnormally short. Only about one third survive 5 years. Even patients who start dialysis in their 40s have no more than a 50% chance to live 5 more years (1).

Nephrologists caring for patients receiving long-term dialysis have studied and improved several factors that contribute to this high mortality, including some technical features of dialysis and various clinical aspects of the care of patients with ESRD. Nevertheless, mortality rates have remained disappointingly high. One area that has received increasing attention over the past decade is the timeliness of referral of persons with chronic renal failure to nephrologists (2, 3). A consensus statement from the National Institutes of Health recommends that patients should be referred as soon as plasma creatinine levels increase to 132 to 177 µmol/L (1.5 to 2.0 mg/dL) (4). There is some evidence that such early intervention by nephrologists may improve …