Castellano et al. in a retrospective analysis of 117 patients showed that patients with an unplanned initiation of dialysis had a lower incidence of permanent vascular access (3.8% vs 83.1%) and higher rate of hospitalization at initiation of dialysis (90.4% vs 6.1%) as well as longer duration of hospitalization and worse biochemical indices.41 However, there was no statistically significant difference in mortality at Ponatinib research buy 6 months. Cooper et al. studied a retrospective cohort of 134 patients.42 Twenty-six started dialysis with a creatinine clearance >10 mL/min and 108 with a creatinine clearance <10 mL/min. The late start group had lower total body nitrogen (a marker of nutritional status)

as well as serum albumin. There was a direct correlation between renal function and total body nitrogen. Devins et al. collected follow-up data on 335 patients with CKD who had participated in an RCT of predialysis psychosocial intervention from the 1980s.43 Mean duration of follow up was 8.5 years.

Median survival was increased by 2.25 years in patients who received this intervention Cisplatin (HR 1.32, 95% CI: 1.0–1.74) and survival after initiation of dialysis was increased by 8 months (HR 1.35, 95% CI: 1.02–1.775). Early referral per se had no survival benefit. Gallego et al. studied 106 patients who were referred early (>6 months) and 33 referred late.44 Late referrals had increased early mortality, hospitalization and emergency dialysis. Long-term survival, however, did not differ between the two groups. The GIMEP group from Italy published a study in 2002

of 1137 patients starting dialysis. This showed that 89% of 616 early referral patients had permanent access at the time of dialysis commencement and 44% started with peritoneal dialysis.45 In contrast, only 0.8% of 521 late referrals (<2 months prior to initiation of dialysis) had permanent access and only 9.1% started with peritoneal dialysis. Of interest, units with a structured predialysis education programme had a greater number of patients starting with permanent access and on peritoneal dialysis. Gøransson and Bergram performed a retrospective study of 242 patients commencing RRT.46 Early referral was defined as >3 months, and late referral as <3 months, prior to initiation of dialysis. Patients were further stratified into three PIK3C2G groups, depending on the years in which they started dialysis. Late referral patients were older, had worse biochemistry and were less likely to be taking medications for hypertension and calcium-phosphate control. Forty-three per cent of early referral patients started dialysis with an AV fistula whereas all late referral patients commenced with temporary venous access. Duration of hospitalization was prolonged in the late referral group (31 days) compared with 7 days in the early referral group. Mortality at 3 months did not differ between the two late and early referral groups.