Comments to the Published Article – Late Referral of Patients with End-stage Renal Disease from Community Hospitals in Northeast Thailand

Dear Editor, We read with great interest the article by Waramit et al., published in Archives of Medical and Health Sciences (2025; 13:165-169) titled “Late Referral of Patients with End-Stage Renal Disease from Community Hospitals in Northeast Thailand,” which examined the determinants and outcomes of delayed nephrology referral in rural district settings.[1] The authors are commended for addressing an underexplored regional disparity in renal care and for providing detailed biochemical and outcome data that illuminate the clinical burden associated with late nephrology engagement. However, several aspects merit critical reconsideration of this study. First, the study defined late referral (≤3 months before dialysis) using a time-to-event threshold adapted from the high-income country literature. This binary cutoff may not reflect the actual care continuum in Thailand’s district-to-tertiary referral system, where diagnostic lag, transportation barriers, and health-insurance gatekeeping differ structurally.[2] A context-specific operational definition, incorporating the first recognition of chronic kidney disease (CKD) in community records or laboratory surveillance intervals, could yield more meaningful estimates of system delay. Clinically, this distinction matters because it separates true provider delay from infrastructural limitations, enabling policy-targeted interventions rather than patient-blaming narratives. Second, the cross-sectional design and reliance on single-point laboratory data precluded the assessment of renal trajectory or prereferral disease control. Although mean creatinine and blood urea nitrogen values were higher in late referrals, the absence of serial glomerular filtration rate data obscures whether late presenters experienced rapid progression or chronic neglect.[3] A prospective registry capturing longitudinal CKD staging and referral timing could clarify the causal pathways between primary care engagement and emergent dialysis initiation, which is crucial for resource-limited settings where early outpatient nephrology visits are scarce. Third, the analysis did not integrate physician or facility-level characteristics, such as laboratory turnaround time, referral capacity, or availability of nephrology outreach programs. Omitting these mesolevel determinants may underestimate the system’s structural contribution to delay.[4] Clinically, identifying facility bottlenecks can guide targeted tele-nephrology or nurse-led screening initiatives within provincial hospitals. Finally, the interpretation of differences in mortality and complications may overstate causality. The early mortality confined to late referrals could partly reflect confounding by disease severity rather than referral timing per se.[5] Adjustment using severity scores (e.g., Charlson Comorbidity Index) or logistic regression would better isolate the effect of the referral interval from the baseline illness burden, an essential refinement for informing triage thresholds. In summary, while this study provides valuable regional insights into late referral patterns, refining the definition of referral delay, incorporating longitudinal and facility-level data, and applying adjusted outcome analyses may enhance translational relevance. Clarifying these aspects could directly inform Thai renal network strategies to expand early CKD detection and reduce the dependence on emergency dialysis. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.