Factor causing late referral of CKD patients to Nephrology care

Introduction: Identifi cation of the disease in its early period changes the outcome. Early reorganition of the chronic kidney disease and a timely referral to nephrologist also affects the prognosis of the disease. The factors which contribute in late referral are well known in the western population. There is a need to look into the factors in our population. Methods: This cross sectional study was conducted in the nephrology unit of Dow university hospital and The Kidney center post graduate medical institute. A structured questionnaire was used to collect the data on sociodemographic characteristics. The stages of CKD were determined by the creatinine clearance or glomerular fi ltration rate at the time of fi rst presentation at hospital. To measure association of stage of CKD with categorical study variables, chi-square test was executed. Level of signifi cance was considered at 5%. Results: Among the different stages of CKD, most of the patients (31.2%) fi rst time presented in the hospital with stage V kidney disease; on the other hand only 8.7% of total patients came in stage 1. Gender, age, socioeconomic status and education were associated with late referral of the CKD patients in the hospital (p value≤ 0.05) while rural and urban residence was not associated with referral time of patients. Conclusion: In conclusion we detected that in our population CKD patients were mostly referred late to nephrology care and the factors that lead to this late referral are increasing age, low socioeconomic status and illiteracy. Research Article Factor causing late referral of CKD patients to Nephrology care Beena Salman1, Muhammad Tahir2, Ruqaya Qureshi1, Murtaza Fakhruddin Dhrolia1, Aasim Ahmad1 and Salman Imtiaz1* 1Department of Nephrology, Dorab Patel Post Graduate Training & Research Center, The Kidney Center Post Graduate Training Institute, 197/9, Rafi qui Shaheed Road, Karachi, Pakistan 2Department of Pediatrics & Child Health, Aga Khan University, Stadium Road, Karachi, Pakistan Dates: Received: 11 May, 2017; Accepted: 15 June, 2017; Published: 19 June, 2017 *Corresponding author: Salman Imtiaz, The Kidney Centre Postgraduate Training Institute. 179/9, Rafi qui Shaheed Road, Karachi, Pakistan, Tel: +93042007270; 3566-1000; Fax: 3566-1040; 3566-1050; E-mail:


Introduction
World health organization showed great concern over morbidity and mortality caused by non-communicable diseases and emphasized them as global priority in a 2005 report. This report focused on cardiovascular diseases, chronic pulmonary conditions, cancers and diabetes which are causing 35 million deaths over a year. Early identifi cation of these diseases change the worse outcomes [1]. Although not included in the agenda of WHO, CKD also has been recognized as an important noncommunicable disease and health care problems [2]. Delayed awareness of the CKD, not only intensifi es the mortality but also induces vascular, infectious, psychological and economical complications [3][4][5][6].
Among different components which intensify the worse outcome of CKD, late referral to nephrologist is of paramount importance .The factors which contribute this late referral are well studied in western population [7][8][9], but very few studies are available in developing countries. The differences in socioeconomic status, health facilities, education level, and provision of public health infrastructure make it impossible to generalize the fi nding of those studies to this population. Therefore, there is a need to evaluate those factor in this population as well.
There is disagreement on the defi nition of late referral, and it varies from 1 month to 6 months before the initiation of hemodialysis. KDICO recommended that patients with CKD should be referred to nephrologist when glomerular fi ltration rate (GFR) decline to less than 30 ml/min [10].
A timely referral to nephrology care improves patient's management in terms of monitoring progression of CKD, planning for the indication of renal replacement therapy and a comprehensive conservative management plan for these who do not opt hemodialysis [11]. The factors which affect referral time to nephrology care are recognized as male gender, diabetic or hypertensive kidney disease, occupation, low activity, and low fi nancial support [12,13].
The aim of the study was to evaluate the factor which effect the referral time to nephrologist in developing country.

Statistical analysis
Data analyses were performed by using software IBM SPSS license version 21. Descriptive analysis of variables was presented in form of frequencies and percentages. To measure association of stage of CKD with categorical study variables, chi-square test was executed. Level of signifi cance was considered at 5%.

Results
The study included 1052 patients in which female were 511(48.6%) while male were 541(51.4%) in numbers. Median age was 55, with minimum of 18 and maximum of 94 years. Larger part of total population of patients (86.8%) was residents of urban areas while 13.2% were residing in rural area. In context with education level, 59.9% were educated, while uneducated patients were 40.1%. Considering the different socioeconomic classes the patients who belonged to middle class were higher in number (53.8%). The majority of the patients (46.2%) were falling in age group from 41-60 years (Table 1) (Table 2).
Age was also highly associated with stage of CKD (p<0.001).
Among the different age groups, 52.7% of patients from 18-40 years came early to the hospital (stage I), while 58.8% of the middle aged patients presented to the hospital in stage II. On the other hand, most of the old age patients came in stage III and stage IV of kidney disease (Table 3).      Education level was also associated with stage of CKD (p = 0.035) as educated people referred early {stage I, II, III (a)} as compare to uneducated patients while uneducated patients came late to hospital (stage IV and V) ( Table 5).
In our study residence was not associated with the presentation of patients to the hospital (p = 0.25) almost same frequency of rural verses urban were in every stage of CKD (Table 6).

Discussion
This study showed that majority of the patients were referred to a nephrologist when their GFR declined to 30 ml / minute. Among them more than quarter reached at stage V with symptomatic uremia and hemodialysis commended on arrival at emergency department. The factors which were associated with the late referral were male gender, older age, lower socio-economic status and low education level. On the other hand, place of residence either rural or urban did not affect the time of referral.
We found that male patients referred late as compared with female. This is consistent with other studies [14].
Age of the patients also effect the time of referral, as we found older the age of the patient, the more his referral was delayed. This might be due to relatively low serum creatinine despite reduced GFR and wrong perception of relatively better kidney function. This is consistent with the other studies [14,15]. Navaneethan and Nigwekar found that, when age was used as a continuous variable it was not signifi cantly associated with late referral but when they analyzed the population of > 75 years of age this association became signifi cant association 12.
Two of the studies one from North America and another from Europe by Arora et al and Wauters et al respectively showed no effect of age on the pattern of referral [16,17].

Conclusion
We come to know from this study, that in our population CKD patients referred late to nephrology care and the factors which lead to this late referral are increasing age, low socioeconomic status and illiteracy. Therefore, we recommend that patient's awareness should be enhanced by the governmental as well as private health sector levels, so CKD patients can be timely managed and complications can be minimized.