Late referral: loss of chance for the patient, loss of money for society.

Despite all efforts to alert the medical community about its multiple detrimental consequences, late nephrological referral of renal patients still remains a frequent problem in all countries. Recent studies show that up to 40% of patients suffering from chronic renal insufficiency (CRI) begin renal replacement therapy (RRT) less than 6 months after being referred to a renal unit, without having benefited from early nephrological care in the predialysis period w1–11x. This situation is most unfortunate as substantial advances have been made in the management of CRI patients. Late referred patients do not benefit from such progress, especially from the renoprotective and cardioprotective strategies that constitute the basis of optimal therapy of CRI patients today w12–16x. Renoprotection (i.e. use of dietary and pharmacological measures aimed at halting or at least slowing progression of renal failure), is currently considered a fundamental goal in the treatment of CRI patients, but it can be fully effective only if implemented from the early stage of renal failure w12,14,17x. Cardioprotection has more recently emerged as another fundamental goal of the treatment of CRI patients in the predialysis phase. Because risk factors for accelerated atherosclerosis, left ventricular hypertrophy and myocardial fibrosis, the main causes of cardiovascular (CV) disease in uraemic patients, develop from an early stage in CRI, cardioprotective therapy should be implemented as early as possible in the course of renal failure to effectively prevent the development of CV disease and reduce the excess CV morbi-mortality that affects uraemic patients w18–20x. In addition, optimal treatment of CRI patients includes prevention of metabolic disorders, prevention of malnutrition, preservation of quality of life, and adequate preparation for RRT. In concrete terms, tight blood pressure control, use of angiotensin II inhibitory drugs, statins, calcium and iron supplements, and phosphate binders, vitamin supplementation, timely use of recombinant erythropoietin, dietary counselling, preservation of nutritional status assessed by serum albumin level, and in-time creation of arteriovenous native fistula are parts of the integrated therapeutic strategy to be offered to predialysis CRI patients w14,18,21,22x. Such management of predialysis CRI patients is complex and requires guidance by a specialist to achieve optimal efficacy and safety. Only early, regular management by a dedicated nephrological team, in close cooperation with other involved physicians, may give the patient his best chances of avoiding, or at least substantially delaying end-stage renal disease (ESRD), and preventing or at least attenuating, uraemic complications. Late referred patients are unfairly deprived of such benefits. Moreover, late referral results in considerable extra cost for the health care system.