When do you refer a patient to nephrology?

When to Refer a Patient to Nephrology

Patients should be referred to nephrology when they have an eGFR <30 mL/min/1.73 m², significant albuminuria (>1 g/day), rapid decline in kidney function, or specific complications of kidney disease that require specialist management. 1

Primary Indications for Nephrology Referral

Based on eGFR

• eGFR <30 mL/min/1.73 m² (CKD stage G4-G5) 1
• Abrupt sustained decrease in eGFR >20% after excluding reversible causes 1
• Rapid progression of CKD (decline in eGFR >5 mL/min/1.73 m² per year) 1

Based on Albuminuria/Proteinuria

• Persistent proteinuria with protein excretion >1 g/day (ACR ≥60 mg/mmol or PCR ≥100 mg/mmol) 1
• Urinary red cell casts or RBC >20 per high power field sustained and not readily explained 1

Based on Complications and Management Issues

• Hypertension refractory to treatment with 4 or more antihypertensive agents 1
• Persistent abnormalities of serum potassium 1
• Recurrent or extensive nephrolithiasis 1
• Hereditary kidney disease 1

Special Considerations

Diabetic Kidney Disease

• Refer patients with diabetes and eGFR <30 mL/min/1.73 m² 1
• Consider referral for patients with diabetes who have:
  • Persistent albuminuria despite optimal treatment 1
  • Difficult management of hypertension or electrolyte disturbances 1
  • Uncertain etiology of kidney disease (absence of retinopathy, heavy proteinuria, active urine sediment) 1

Planning for Renal Replacement Therapy

• Refer patients with progressive CKD in whom the risk of kidney failure within 1 year is 10-20% or higher 1
• Adequate preparation for dialysis or transplantation requires at least 12 months of relatively frequent contact with a renal care team 2, 3

Acute Kidney Injury (AKI)

• AKI in primary care can often be managed by treating the precipitating cause, temporarily discontinuing RAS blockade and NSAIDs, and correcting obstruction 1
• Refer to nephrology if there are features suggestive of a diagnosis other than prerenal azotemia or acute tubular necrosis 1

Exceptions to Referral

• Patients with eGFR <30 mL/min/1.73 m² may not require referral if: 1
  • GFR is stable
  • Diagnosis is relatively clear
  • Very advanced age or presence of comorbidity indicates a short life expectancy

Benefits of Early Referral

• Identification and treatment of reversible causes of renal failure 2, 4
• Slowing the rate of decline associated with progressive renal insufficiency 2, 3
• Better management of coexisting conditions associated with chronic renal failure 2, 4
• More efficient entry into dialysis programs for patients who might benefit 2, 3
• Improved survival after initiation of hemodialysis 3

Multidisciplinary Care Approach

• Patients with progressive CKD who are at high risk of ESRD with eGFRs <30 mL/min/1.73 m², those with rapid progression, or those with complex comorbidity may benefit from a multidisciplinary approach 1
• The multidisciplinary team should include or have access to dietary counseling, education about different renal replacement therapy options, transplant options, vascular access surgery, and ethical, psychological, and social care 1

Common Pitfalls to Avoid

• Late referral (less than 1 year before start of renal replacement therapy) is associated with worse outcomes 1, 3
• Not recognizing non-diabetic kidney disease in patients with diabetes (absence of retinopathy, heavy proteinuria, active urine sediment) 1
• Discontinuing ACE inhibitors or ARBs for minor increases in serum creatinine (<30%) in the absence of volume depletion 1, 5
• Failing to adjust medication dosages in patients with decreased kidney function 1, 5