Referral patterns in the CKD.QLD Registry: A call for revisiting the definition of late referral

Abstract

Abstract Background The rising burden of chronic kidney disease (CKD) requires reinforcing of the current mechanisms for early detection and intervention. Although ‘timely’ referral to a specialist nephrology service plays a crucial role for many patients in ensuring improved outcomes, the lack of widely accepted definitions of timely (and by implication, early and late) referral may limit such outcomes. Study aim To evaluate referral patterns among CKD.QLD Registry participants, focusing on the timing and appropriateness of referrals and their association with clinical outcomes. Methods We conducted a retrospective cohort study of adults (≥18 years) enrolled in the CKD.QLD Registry from seven public nephrology clinics between May 2011 and June 2018. Participants were followed until kidney replacement therapy (KRT), death, or study closure. All CKD stages were included to assess demographic and clinical characteristics at referral and associated outcomes. Late referral was defined as initiation of KRT within 12 months of the first nephrology visit among those who progressed to KRT. Results Among 3,775 participants (median age 65 years; 54.8% male; 8.7% Indigenous), hypertension (77.5%) and type 2 diabetes (44.9%) were the most common comorbidities. ESKD developed in 775 (20.5%) participants; 513 (66.2%) received KRT. Overall, 722 (19.1%) died, including 124 (17.2%) after starting KRT. Late referral occurred in 60 (11.7%) KRT participants, with 15 (25%) deaths, 3 within 12 months of KRT initiation. Most KRT patients (77.4%) and deaths (65.5%) were in the high-comorbidity group; among KRT-related deaths, 101 (81.5%) were high-comorbidity, and 351 (88.4%) were referred early. Conclusion Late referral rates were lower than previously reported. Comorbidity burden, rather than referral timing, was the stronger predictor of mortality. These findings highlight the need for a standardized definition of late referral that incorporates risk stratification.