From the Guidelines
The patient should see a nephrologist and a rheumatologist. Given the combination of elevated ferritin and creatinine in a patient with rheumatoid arthritis (RA), a coordinated approach between these specialists is important. The elevated creatinine suggests kidney dysfunction, which could be related to RA itself (as rheumatoid arthritis can cause kidney complications), medication side effects from RA treatments (such as NSAIDs or certain DMARDs), or an unrelated kidney condition. The elevated ferritin could be due to inflammation from RA, but when combined with kidney issues, it warrants comprehensive evaluation.
Key Considerations
- The nephrologist will assess kidney function, potentially order additional tests like urinalysis, kidney ultrasound, or biopsy if needed, and manage the kidney-related aspects of care.
- Meanwhile, the rheumatologist should review the patient's current RA treatment regimen to ensure it's not contributing to kidney problems while still effectively managing the RA, as recommended by the EULAR guidelines for the management of rheumatoid arthritis 1.
- This dual-specialist approach ensures both conditions receive appropriate attention and that treatments are coordinated to avoid worsening either condition.
Referral Guidelines
- Referral to a nephrologist is recommended for patients with uncertainty about the etiology of kidney disease, difficult management issues, or rapidly progressing kidney disease, as stated in the standards of medical care in diabetes-2022 1 and standards of care in diabetes-2023 1.
- The Canadian Society of Nephrology commentary on the KDIGO clinical practice guideline for CKD evaluation and management also supports referral to a nephrologist for patients with persistent proteinuria or uncertainty about the diagnosis 1.
- The KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD suggests that referral should be tailored to the specific needs of the patient and the provider’s capacity to deliver specialty care 1.
From the Research
Patient Referral
Given the patient's elevated ferritin and creatinine levels, along with a diagnosis of Rheumatoid Arthritis (RA), it is essential to consider the potential renal involvement associated with RA. The patient should be referred to:
- A nephrologist, as earlier referral is expected to lead to better health care outcomes and lower costs for both the patients and the health care system 2
- A rheumatologist, to manage the RA and its potential renal manifestations, as renal involvement can develop due to the disease itself or secondary to drugs used in the treatment 3, 4
Management Considerations
When managing the patient's condition, the following should be considered:
- The potential nephrotoxicity of medications used to treat RA, such as NSAIDs, methotrexate, and tofacitinib, which may need to be adjusted or avoided in patients with renal dysfunction 5, 4
- The importance of diagnosing and managing renal involvement at an early stage, as it can herald a poor prognosis and warrants aggressive immunosuppressive treatment 3
- The need for adequate preparation for dialysis or transplantation, which requires at least 12 months of relatively frequent contact with a renal care team 2