Document Detail

Late referral to a nephrologist increases the risk of uremia-related cardiac hypertrophy in patients on hemodialysis.
MedLine Citation:
PMID:  17957125     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: The prognosis and outcome of patients with end-stage renal disease are related to the quality of predialysis care and the timing of referral. Late referral (LR) has been correlated with more frequent hospital admissions, malnutrition and cardiovascular mortality after hemodilaysis (HD) is started. METHODS: We investigated the effects of LR on cardiac hypertrophy, uremia-related metabolic risk factors and mortality in patients on HD. A baseline echocardiography was performed in 119 patients on HD, 67 of whom were early referrals (ER, referred more than 3 months before the start of HD) and 52 were LR (referred less than 3 months before the start of HD; median (range): 22.5 (4-120) vs. 1.0 (0-3) months, respectively). RESULTS: The survival curves showed a higher mortality rate in the LR patients than in the ER patients (log rank, p = 0.004). More patients in the LR group died of cardiovascular disease compared to the ER patients (p = 0.04). The plasma levels of albumin were significantly lower (p < 0.05), and the intact parathyroid hormone (iPTH) and log C-reactive protein (log CRP) were significantly higher in the LR patients compared to the ER patients (p < 0.05 and p < 0.001, respectively). The LR patients, especially nonsurvivors, showed greater impairment of systolic cardiac function and more concentric left ventricular hypertrophy (LVH) than ER patients, as determined by interventricular septal thickness (p < 0.001), left ventricular posterior wall thickness (p < 0.001), relative wall thickness (p = 0.02), and the left ventricular mass index (LVMi, p < 0.001). Interestingly, the duration of the pre-HD treatment, after referral, was positively associated with the plasma albumin (r = 0.229; p = 0.01) and negatively associated with the log CRP (r = -0.350; p < 0.001), iPTH (r = -0.309; p = 0.001) and LVMi (r = -0.268; p = 0.004). Multiple linear regression analysis also demonstrated that the log CRP and iPTH as well as the LR were independently associated with LVMi in the HD patients (p < 0.05). CONCLUSIONS: The results of this study demonstrated that the LR HD patients were at an increased risk for more cardiovascular related mortality, severe concentric LVH and systolic dysfunction accompanied by inflammatory and malnutrition indices, as well as with increased iPTH levels. In the LR patients, the more severe LVH associated with severe inflammatory indices, as well as the higher iPTH levels, may be one of the causes of LR-related mortality.
Seok Joon Shin; Hyung Wook Kim; Sungjin Chung; Hyun Wha Chung; Sang Ju Lee; Yong Soo Kim; Byung Kee Bang; Yoon Sik Chang; Cheol Whee Park
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Publication Detail:
Type:  Comparative Study; In Vitro; Journal Article     Date:  2007-10-22
Journal Detail:
Title:  Nephron. Clinical practice     Volume:  107     ISSN:  1660-2110     ISO Abbreviation:  Nephron Clin Pract     Publication Date:  2007  
Date Detail:
Created Date:  2008-01-10     Completed Date:  2008-02-05     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101159763     Medline TA:  Nephron Clin Pract     Country:  Switzerland    
Other Details:
Languages:  eng     Pagination:  c139-46     Citation Subset:  IM    
Copyright Information:
(c) 2007 S. Karger AG, Basel
Division of Nephrology, Department of Internal Medicine, St. Vincent's and St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea.
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MeSH Terms
Age Distribution
Cause of Death*
Cohort Studies
Echocardiography, Doppler
Hypertrophy, Left Ventricular / epidemiology*,  etiology*,  ultrasonography
Linear Models
Middle Aged
Nephrology / standards,  trends
Reference Values
Referral and Consultation / standards*,  trends
Renal Dialysis / adverse effects*,  methods
Risk Assessment
Sex Distribution
Survival Analysis
Time Factors
Uremia / complications*,  diagnosis,  therapy

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