• Ping Liu, Robert R Quinn, Mohammad Ehsanul Karim, Aminu Bello, Helen Tam-Tham, Robert Weaver, Paul E Ronksley, Hude Quan, Strippoli Giovanni F M GFM Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), Unive, Braden Manns, Brenda R Hemmelgarn, Marcello Tonelli, and Pietro Ravani.
• Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy.
• CMAJ. 2019 Mar 11; 191 (10): E274-E282.

BackgroundGuidelines recommend nephrology referral for people with advanced non-dialysis-dependent chronic kidney disease, based mostly on survival benefits seen in retrospective studies of dialysis patients, which may not be generalizable to the broader population with chronic kidney disease. We aimed to examine the association between outpatient nephrology consultation and survival in adults with stage 4 chronic kidney disease.MethodsWe linked population-based laboratory and administrative data from 2002 to 2014 in Alberta, Canada, on adults with stage 4 chronic kidney disease (sustained estimated glomerular filtration rate ≥ 15 to < 30 mL/min/1.73 m2 for > 90 d), who had never had kidney failure and had had no outpatient nephrology encounter in the 2 years preceding study entry. Participants who had never had an outpatient nephrology visit before renal replacement treatment were considered "unexposed." Participants who saw a nephrologist during follow-up were considered "unexposed" before the first outpatient nephrology visit and "exposed" thereafter. The primary outcome was all-cause mortality.ResultsOf the 14 382 study participants (median follow-up 2.7 yr), 64% were aged ≥ 80 years, 35% saw a nephrologist and 66% died during follow-up. Nephrology consultation was associated with lower mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82-0.93). The association was strongest in people < 70 years (HR 0.78, 95% CI, 0.65-0.92), progressively weaker with increasing age, and absent in people ≥ 90 years (HR 1.05, 95% CI 0.88-1.25).InterpretationThe survival benefit of nephrology consultation in adults with stage 4 chronic kidney disease may be smaller than expected and appears to attenuate with increasing age. These findings should inform recommendations for nephrology referral considering the advanced age of the patient population meeting current referral criteria.© 2019 Joule Inc. or its licensors.

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