Nephrology referral and appropriateness of therapeutic drug care in chronic kidney disease

Background: Rates of morbidity and mortality remain high among patients with chronic kidney disease, but depend to some extent on modifiable factors such as the therapeutic drug care provided. Methods: This prospective community-based study assessed the impact of early nephrology referral on the drug treatments of a consecutive series of patients. More than 98% of patients with end-stage renal disease, living in a French region, who began kidney replacement therapy (KRT) between 1997 and 1999 were enrolled. They were classified into 5 groups according to the timing of the 1st serum creatinine reading in excess of 2 mg/dL and the 1st visit to a nephrologist. The drugs prescribed and the appropriateness of therapeutic care at the initiation of KRT and 6 months later were compared between groups. Results: Five hundred and two patients were included. On initiation of KRT, early referral patients were more likely than other groups to be receiving epoetin, iron salts, phosphate binders, synthetic vitamin D, and/or ACE inhibitors. The earlier the nephrology care, the more appropriate was treatment by epoetin, phosphate binders and vitamin D. Six months later, the 5 groups did not differ in the drugs prescribed or their appropriateness. Conclusions: This study provides evidence of an association between the timing of nephrology referral and the quality of therapeutic drug care at the start of KRT. Later, when all patients are under the care of a nephrologist, drug treatments are no longer related to the timing of referral.