Importance of age and timing of referral when initiating dialysis

TL;DR

Older patients starting dialysis later have worse survival and more hospital stays, while early referral improves outcomes.

Contribution

Shows that late referral to a nephrologist worsens outcomes in elderly dialysis patients compared to younger patients.

Findings

Late referral increases one-year mortality risk in patients over 75 years.

Elderly patients with late referral have more hospitalization days per year.

Early referral in elderly patients leads to better outcomes similar to younger patients.

Abstract

Mortality of patients > 75 years of age initiating dialysis is high. Late referral to a nephrologist prior to dialysis initiation is associated with poor outcomes. Herein, we report the outcomes of patients initiating dialysis according to their age and timing of referral.

We reviewed a prospective cohort of patients initiating dialysis from 2000 to 2022 at a single university center. Primary outcome was one-year all-cause mortality. Secondary outcomes were overall all-cause mortality and one-year hospitalization days. Late referral was defined as dialysis initiation < 1 month after a first consultation with a nephrologist.

We included 906 patients, including 246 (27%) aged over  75 years. Late referral was more common in elderly patients compared to younger ones, with rates of 26% and 34%, respectively (p = 0.027). Regarding one-year mortality, considering patients aged over 75 years with early referral as the reference, patients aged > 75 years with late referral were at higher risk (Hazard Ratio [HR] 2.30, p = 0.001), while patients aged < 75 years with either early or late referral were at similar risk. Regarding overall mortality, patients aged > 75 years with late referral were at higher risk (HR 1.56, p = 0.002), while patients aged < 75 years with either early (HR 0.65, p < 0.001) or late referral (HR 0.62, p = 0.001) were at lower risk. Finally, patients aged over 75 years with late referral had more hospitalization days per year (coef 0.09, p < 0.001), while patients < 75 years with either early (coef − 0.07, p < 0.001) or late referral (coef − 0.05, p < 0.001) had fewer hospitalization days per year.

Late referral of elderly patients prior to dialysis initiation is common and adversely associated with short- and long-term mortality as well as hospitalization days. Conversely, early referral of elderly patients is associated with a favorable short-term prognosis that is comparable to that of younger patients.

The online version contains supplementary material available at 10.1007/s40620-025-02390-7.

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