Cass and colleagues also looked at the association between social disadvantage and late referral in 3334 patients from the ANZDATA Registry.7 The patient’s postcode at the start of treatment was used as an indicator of place of residence. The analysis was restricted to capital cities to

exclude remote area patients who would have moved home to more easily access dialysis. Australian Bureau of Epigenetic Reader Domain inhibitor Statistics data allowed correlation between the postcode and an index of socioeconomic disadvantage. A total of 889 patients (26.7%) were referred late with a range from 13.6% to 43.7% between geographical areas. The areas with the higher percentage of late referrals were those of relative disadvantage – the highest being Darwin, with a large indigenous community. Disadvantaged areas

also had a higher burden of ESKD. Curtis et al. studied 288 patients who commenced dialysis following more than 3 months’ exposure to nephrology care.8 Patients seen in multidisciplinary clinics had significantly increased survival at 14 months compared with standard nephrological care, with the hazard ratio for mortality for standard versus multidisciplinary care being 2.17 (95% CI: 1.11–4.28). Frimat et al. reviewed 148 patients with type 2 diabetes who commenced dialysis in the EPIREL study.9 Mortality within 3 months of renal replacement therapy was associated with physical impairment in ambulation and commencing dialysis in life-threatening circumstances. Commencement of dialysis in an emergency was associated with late referral (<3 months), worse biochemistry and increased hospitalization. After 3 months, survival see more at 1 year was 16.4% better in those with regular nephrological care versus late referral. Fujimaki and Kasuya studied 119 patients older than 60 years of age

(mean age = 74 years) and showed increased need for urgent initiation of dialysis in late referred patients.10 Urgent dialysis was associated with increased mortality. In a study of 101 Brazilian patients commencing haemodialysis, Gonçalves et al. showed increased mortality and hospitalization in late referred patients (<3 months prior to initiation of dialysis) and in patients with temporary venous access.11 By univariate analysis, late referral (HR 10.77, 95% CI: 1.41–82.45) and albumin (HR 0.23, 95%CI: 0.11–0.47) were associated with reduced Nitroxoline survival. By multivariate analysis, only late referral was associated with increased hospitalization (HR 3.51). Late referral was associated with increased mortality and hospitalization, independently of temporary venous access. John et al. identified 3822 patients with CKD (median calculated GFR 28 mL/min per 1.73 m2) from biochemical samples processed at two laboratories in Kent, UK, who were unknown to the renal service.12 At 31.3 months, 8.1% of these patients had been referred. Unreferred patients had a median survival of 28.1 months. The majority had stable renal function but 27.