From the Guidelines
A patient with impaired renal function should typically be referred to a nephrologist first, as they specialize in managing kidney diseases and preserving kidney function. The decision to refer a patient to a nephrologist or a urologist depends on the underlying cause of the renal impairment. Nephrologists focus on medical management to preserve kidney function through medications, dietary modifications, and monitoring of kidney function parameters, making them the primary choice for patients with impaired renal function due to conditions like chronic kidney disease, glomerulonephritis, or electrolyte disorders 1. Some key points to consider when deciding on a referral include:
- The patient's glomerular filtration rate (GFR), with a threshold of eGFR <30 mL/min/1.73 m² often prompting referral to a nephrologist for discussion of renal replacement therapy 1
- Uncertainty about the etiology of kidney disease, difficult management issues, or advanced kidney disease requiring discussion of renal replacement therapy, all of which may necessitate a nephrologist's expertise 1
- The presence of structural or obstructive issues affecting the urinary tract, which may require a urologist's intervention, such as kidney stones, urinary tract obstructions, or cancers of the urinary system
- The importance of collaborative care between specialists, with nephrologists managing medical aspects of kidney disease and urologists addressing surgical needs Primary care physicians typically initiate referral to a nephrologist when patients show persistent abnormal kidney function tests, significant proteinuria, or declining GFR, highlighting the need for timely referral to a specialist when kidney function is impaired 1.
From the Research
Referral to a Nephrologist or Urologist
For a patient with impaired renal function, the decision to refer them to a urologist or a nephrologist depends on the specific condition and needs of the patient.
- A nephrologist is a specialist who deals with the diagnosis, treatment, and management of kidney disorders and diseases, such as chronic kidney disease, kidney failure, and kidney stones 2.
- A urologist, on the other hand, is a specialist who deals with the diagnosis, treatment, and management of disorders and diseases of the urinary tract and the male reproductive system, such as prostate cancer, bladder cancer, and urinary incontinence.
Signs of Renal Disease
According to 2, signs of renal disease include:
- Renal hematuria
- Microalbuminuria
- Proteinuria
- Limited renal filtration function
- Glomerular filtration rate (GFR) abnormalities
- Renal cysts
Benefits of Nephrologist Referral
Studies have shown that referral to a nephrologist can improve patient outcomes, including:
- Delayed progression of chronic kidney disease 3
- Improved survival rates 4, 5
- Reduced mortality rates 4, 5
Timing of Referral
The timing of referral to a nephrologist is also important, with earlier referral associated with better outcomes 5. According to 3, an appropriate time for nephrology comanagement of patients with chronic kidney disease may be stage 3.
Patient Groups with Poor Access to Specialist Renal Services
Certain patient groups, such as older patients and those living in deprived areas, may have poor access to specialist renal services 6. However, contrary to other diseases, disadvantaged patients do not seem to be under-investigated for renal disease compared with their more affluent neighbors and are generally referred earlier for specialist assessment 6.