The Referral Pattern of End-Stage Renal Disease Patients and the Initiation of Dialysis: A European Perspective

D esPite impressive progress in the medical care of endstage renal disease (ESRD) patients, ESRD is still associated with an unacceptably high mortality rate. To improve the management ofESRD patients, both medical and non medical problems should be addressed (1). It is conceivable that adequate pre-dialysis programs can improve the outcomes provided that patients are referred early to the renal unit and that sufficient resources are available. The latter condition to some extent depends on the health care structure of a given society (2). The present paper focuses on one important determinant ofESRD treatment in several European countries: the influence that the referral pattern ofESRD patients to the renal units has on the choice oftreatment modality, the clinical status of the patients at initiation of dialysis, and patient outcome. This discussion is based on the results of a multicenter European survey on the referral patterns of ESRD patients, extending a previously limited analysis (3) by providing data on patient outcome and on clinical and biochemical parameters at initiation of renal replacement therapy (RRT). Although the optimal moment for the initiation of RRT is still debated, there is evidence that a toolate start has detrimental and partly irreversible consequences for the outcome of the patient (4-7). It is conceivable that, besides the attention given to a number of secondary medical complications during the pre-ESRD phase, non medical factors such as education and information ofpre-ESRD patients may also exert a positive impact on their prognosis (8,9). In a previous study comprising 14 different Euro pean dialysis units (3), it was demonstrated that in