From the Guidelines
Referral to a nephrologist for dialysis consideration is generally recommended when the glomerular filtration rate (GFR) falls below 30 mL/min/1.73m². This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of early referral to a nephrologist for patients with chronic kidney disease (CKD) to improve outcomes and prepare for kidney replacement therapy 1.
Key Considerations for Referral
- GFR below 30 mL/min/1.73m²
- Significant albuminuria (UACR 300 mg/g)
- Progression of DKD to a new CKD category
- Abrupt, sustained decline in eGFR of more than 5 mL/min per 1.73 m2 per year
Benefits of Early Referral
- Improved management of complications as the disease worsens
- Preparation for kidney replacement therapy
- Increased appropriate use of renin-angiotensin-aldosterone system blockers
- Optimal management of comorbidities, such as anemia, hypertension, and CKD mineral and bone disorders
Timing of Dialysis Initiation
The timing of actual dialysis initiation depends not only on GFR but also on the presence of uremic symptoms, fluid overload unresponsive to diuretics, refractory hyperkalemia, metabolic acidosis, or pericarditis. Some patients may remain relatively asymptomatic despite very low GFR values, while others develop complications requiring dialysis at higher GFR levels.
Outcomes of Early Nephrology Referral
Early nephrology referral is associated with better outcomes, including improved survival on dialysis, increased likelihood of arteriovenous fistula placement before dialysis initiation, and greater opportunity for preemptive kidney transplantation evaluation 1.
From the Research
Referral to a Nephrologist for Dialysis
The decision to refer a patient to a nephrologist for dialysis is based on several factors, including the patient's glomerular filtration rate (GFR). According to the studies, the following GFR values are considered indicators for referral:
- GFR < 30 mL/min/1.73 m2 2, 3, 4, 5, 6
- GFR ≤ 60 mL/min/1.73 m2 in the presence of various cofactors, such as albuminuria or rapid decline in GFR 3
- GFR < 15 mL/min/1.73 m2, at which point renal replacement therapy should be considered 6
Indications for Nephrology Referral
The studies also highlight the importance of referring patients to a nephrologist based on other indicators, including:
- Proteinuria 4
- Uncontrolled hypertension 4
- Hyperkalemia 4
- Anemia of CKD 4
- Bone disorder of CKD 4
- Rapid decline in GFR 2, 4
Timing of Referral
The timing of referral to a nephrologist is crucial, as late referral can lead to suboptimal pre-end stage renal disease care and greater mortality 4, 6. The studies emphasize the importance of early referral, ideally when the patient's GFR approaches 30 mL/min/1.73 m2 2, 5.