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Q) When should I refer patients with chronic kidney disease (CKD) to a nephrology specialist?
Nephrology specialists can be of particular assistance to primary care providers in treating patients who are at different stages of CKD.1 Nephrologists can help determine the etiology of CKD, recommend specific disease-related therapy, suggest treatments to delay disease progression in patients who have not responded to conventional therapies, recognize and treat for disease-related complications, and plan for renal replacement therapy.1
Indications for referral vary across guidelines but there is one commonality: Patients with a severely decreased estimated glomerular filtration rate (eGFR) of < 30 mL/min per 1.73 m2 require prompt referral to a nephrologist for comanaged care.1-4 Patients with CKD who have an eGFR at or below this threshold are likely at an advanced stage of disease and are therefore at greater risk for progression to end-stage renal disease (ESRD), which requires dialysis.1 Research shows that late referral to nephrology is associated with significantly higher rates of mortality within the first 90 days of dialysis.5 Furthermore, the Renal Physicians Association Clinical Practice Guideline states that patients with advanced CKD (stages 4 and 5) have a greater predisposition for quick progression to ESRD with multiple comorbid conditions and poor outcomes.6
Clinical outcomes can improve when referrals are made before patients with CKD register a low eGFR—but the appropriate threshold (or when to refer patients with a higher eGFR) is less clear.1 Based in part on practice guidelines,2,3,6,7 referral to a nephrologist or clinician with expertise in CKD should be considered for patients with CKD who meet 1 or more of the following criteria:
- Urine albumin-to-creatinine ratio > 300 mg/g (34 mg/mmoL), including nephrotic syndrome
- Hematuria that is not secondary to urologic conditions
- Inability to identify a presumed cause of CKD
- eGFR decline of > 30% in less than 4 months without an obvious explanation
- Difficult-to-manage complications, such as anemia requiring erythropoietin therapy or abnormalities of bone and mineral metabolism requiring phosphorus binders or vitamin D preparations
- Serum potassium > 5.5 mEq/L
- Difficult-to-manage drug complications
- Age < 18 y
- Resistant hypertension
- Recurrent or extensive nephrolithiasis
- Confirmed or presumed hereditary kidney disease (eg, polycystic kidney disease, Alport syndrome, or autosomal dominant interstitial kidney disease).1,2,4,7
These criteria can aid clinicians in deciding when a preemptive referral is needed to prevent advanced CKD stages and ESRD in their patients. Also, because patients with CKD can be at high risk for adverse cardiovascular outcomes, referral to cardiology (eg, for patients with complicated cardiovascular disease) should be considered.1–YTM
Yolanda Thompson-Martin, DNP, RN, ANP-C, FNKF
University Health Physicians/Truman Medical Center, Kansas City, Missouri
1. Levey AS, Inker LA. Definition and staging of chronic kidney disease in adults. UpToDate. www.uptodate.com/contents/definition-and-staging-of-chronic-kidney-disease-in-adults. Accessed January 29, 2020.
2. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J of Kidney Dis. 2002;39(suppl 1):S1-S266.
3. Kidney Disease Outcomes Quality Initiative (K/DOQI). K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43(suppl 1):11-13.
4. Luxton G; Caring for Australasians with Renal Impairment. The CARI Guidelines. Timing of referral of chronic kidney disease patients to nephrology services (adult). Nephrology (Carlton). 2010;15(suppl 1):S2-S11.
5. Jungers P, Massy Z, Nguyen-Khoa T, et al. Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant. 2001;16(12):2357-2364.
6. WK Bolton. Renal Physicians Association Clinical Practice Guidelines: appropriate patient preparation for renal replacement therapy: guide line number 3. J Am Soc Nephrol. 2003;14(5):1406-1410.
7. Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guidelines for the evaluation and management of chronic kidney disease. Kidney Int. 2013;3(suppl):1-150.
Clinician Reviews in partnership with
The National Kidney Foundation Council of Advanced Practitioners' (NKF-CAP) mission is to serve as an advisory resource for the NKF, nurse practitioners, physician assistants, clinical nurse specialists, and the community in advancing the care, treatment, and education of patients with kidney disease and their families. CAP is an advocate for professional development, research, and health policies that impact the delivery of patient care and professional practice. For more information on NKF-CAP, visit www.kidney.org/CAP. Renal Consult is edited by Christine Corbett, DNP, APRN, FNP-BC, CNN-NP, FNKF, Corporate Director of Advanced Practice Providers and Nurse Practitioner, Nephrology, at Truman Medical Centers, Kansas City, Missouri, and Leah Foster Smith, MSN, APRN, FNP-BC, CNN-NP, FNKF, Director of Advanced Practitioners and Nephrology Nurse Practitioner at Metrolina Nephrology Associates, PA, in Charlotte, North Carolina. This month's column was authored by Yolanda Thompson-Martin, who practices at University Health Physicians/Truman Medical Center, Kansas City, Missouri.
Clinician Reviews in partnership with
The National Kidney Foundation Council of Advanced Practitioners' (NKF-CAP) mission is to serve as an advisory resource for the NKF, nurse practitioners, physician assistants, clinical nurse specialists, and the community in advancing the care, treatment, and education of patients with kidney disease and their families. CAP is an advocate for professional development, research, and health policies that impact the delivery of patient care and professional practice. For more information on NKF-CAP, visit www.kidney.org/CAP. Renal Consult is edited by Christine Corbett, DNP, APRN, FNP-BC, CNN-NP, FNKF, Corporate Director of Advanced Practice Providers and Nurse Practitioner, Nephrology, at Truman Medical Centers, Kansas City, Missouri, and Leah Foster Smith, MSN, APRN, FNP-BC, CNN-NP, FNKF, Director of Advanced Practitioners and Nephrology Nurse Practitioner at Metrolina Nephrology Associates, PA, in Charlotte, North Carolina. This month's column was authored by Yolanda Thompson-Martin, who practices at University Health Physicians/Truman Medical Center, Kansas City, Missouri.
Clinician Reviews in partnership with
The National Kidney Foundation Council of Advanced Practitioners' (NKF-CAP) mission is to serve as an advisory resource for the NKF, nurse practitioners, physician assistants, clinical nurse specialists, and the community in advancing the care, treatment, and education of patients with kidney disease and their families. CAP is an advocate for professional development, research, and health policies that impact the delivery of patient care and professional practice. For more information on NKF-CAP, visit www.kidney.org/CAP. Renal Consult is edited by Christine Corbett, DNP, APRN, FNP-BC, CNN-NP, FNKF, Corporate Director of Advanced Practice Providers and Nurse Practitioner, Nephrology, at Truman Medical Centers, Kansas City, Missouri, and Leah Foster Smith, MSN, APRN, FNP-BC, CNN-NP, FNKF, Director of Advanced Practitioners and Nephrology Nurse Practitioner at Metrolina Nephrology Associates, PA, in Charlotte, North Carolina. This month's column was authored by Yolanda Thompson-Martin, who practices at University Health Physicians/Truman Medical Center, Kansas City, Missouri.
Q) When should I refer patients with chronic kidney disease (CKD) to a nephrology specialist?
Nephrology specialists can be of particular assistance to primary care providers in treating patients who are at different stages of CKD.1 Nephrologists can help determine the etiology of CKD, recommend specific disease-related therapy, suggest treatments to delay disease progression in patients who have not responded to conventional therapies, recognize and treat for disease-related complications, and plan for renal replacement therapy.1
Indications for referral vary across guidelines but there is one commonality: Patients with a severely decreased estimated glomerular filtration rate (eGFR) of < 30 mL/min per 1.73 m2 require prompt referral to a nephrologist for comanaged care.1-4 Patients with CKD who have an eGFR at or below this threshold are likely at an advanced stage of disease and are therefore at greater risk for progression to end-stage renal disease (ESRD), which requires dialysis.1 Research shows that late referral to nephrology is associated with significantly higher rates of mortality within the first 90 days of dialysis.5 Furthermore, the Renal Physicians Association Clinical Practice Guideline states that patients with advanced CKD (stages 4 and 5) have a greater predisposition for quick progression to ESRD with multiple comorbid conditions and poor outcomes.6
Clinical outcomes can improve when referrals are made before patients with CKD register a low eGFR—but the appropriate threshold (or when to refer patients with a higher eGFR) is less clear.1 Based in part on practice guidelines,2,3,6,7 referral to a nephrologist or clinician with expertise in CKD should be considered for patients with CKD who meet 1 or more of the following criteria:
- Urine albumin-to-creatinine ratio > 300 mg/g (34 mg/mmoL), including nephrotic syndrome
- Hematuria that is not secondary to urologic conditions
- Inability to identify a presumed cause of CKD
- eGFR decline of > 30% in less than 4 months without an obvious explanation
- Difficult-to-manage complications, such as anemia requiring erythropoietin therapy or abnormalities of bone and mineral metabolism requiring phosphorus binders or vitamin D preparations
- Serum potassium > 5.5 mEq/L
- Difficult-to-manage drug complications
- Age < 18 y
- Resistant hypertension
- Recurrent or extensive nephrolithiasis
- Confirmed or presumed hereditary kidney disease (eg, polycystic kidney disease, Alport syndrome, or autosomal dominant interstitial kidney disease).1,2,4,7
These criteria can aid clinicians in deciding when a preemptive referral is needed to prevent advanced CKD stages and ESRD in their patients. Also, because patients with CKD can be at high risk for adverse cardiovascular outcomes, referral to cardiology (eg, for patients with complicated cardiovascular disease) should be considered.1–YTM
Yolanda Thompson-Martin, DNP, RN, ANP-C, FNKF
University Health Physicians/Truman Medical Center, Kansas City, Missouri
Q) When should I refer patients with chronic kidney disease (CKD) to a nephrology specialist?
Nephrology specialists can be of particular assistance to primary care providers in treating patients who are at different stages of CKD.1 Nephrologists can help determine the etiology of CKD, recommend specific disease-related therapy, suggest treatments to delay disease progression in patients who have not responded to conventional therapies, recognize and treat for disease-related complications, and plan for renal replacement therapy.1
Indications for referral vary across guidelines but there is one commonality: Patients with a severely decreased estimated glomerular filtration rate (eGFR) of < 30 mL/min per 1.73 m2 require prompt referral to a nephrologist for comanaged care.1-4 Patients with CKD who have an eGFR at or below this threshold are likely at an advanced stage of disease and are therefore at greater risk for progression to end-stage renal disease (ESRD), which requires dialysis.1 Research shows that late referral to nephrology is associated with significantly higher rates of mortality within the first 90 days of dialysis.5 Furthermore, the Renal Physicians Association Clinical Practice Guideline states that patients with advanced CKD (stages 4 and 5) have a greater predisposition for quick progression to ESRD with multiple comorbid conditions and poor outcomes.6
Clinical outcomes can improve when referrals are made before patients with CKD register a low eGFR—but the appropriate threshold (or when to refer patients with a higher eGFR) is less clear.1 Based in part on practice guidelines,2,3,6,7 referral to a nephrologist or clinician with expertise in CKD should be considered for patients with CKD who meet 1 or more of the following criteria:
- Urine albumin-to-creatinine ratio > 300 mg/g (34 mg/mmoL), including nephrotic syndrome
- Hematuria that is not secondary to urologic conditions
- Inability to identify a presumed cause of CKD
- eGFR decline of > 30% in less than 4 months without an obvious explanation
- Difficult-to-manage complications, such as anemia requiring erythropoietin therapy or abnormalities of bone and mineral metabolism requiring phosphorus binders or vitamin D preparations
- Serum potassium > 5.5 mEq/L
- Difficult-to-manage drug complications
- Age < 18 y
- Resistant hypertension
- Recurrent or extensive nephrolithiasis
- Confirmed or presumed hereditary kidney disease (eg, polycystic kidney disease, Alport syndrome, or autosomal dominant interstitial kidney disease).1,2,4,7
These criteria can aid clinicians in deciding when a preemptive referral is needed to prevent advanced CKD stages and ESRD in their patients. Also, because patients with CKD can be at high risk for adverse cardiovascular outcomes, referral to cardiology (eg, for patients with complicated cardiovascular disease) should be considered.1–YTM
Yolanda Thompson-Martin, DNP, RN, ANP-C, FNKF
University Health Physicians/Truman Medical Center, Kansas City, Missouri
1. Levey AS, Inker LA. Definition and staging of chronic kidney disease in adults. UpToDate. www.uptodate.com/contents/definition-and-staging-of-chronic-kidney-disease-in-adults. Accessed January 29, 2020.
2. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J of Kidney Dis. 2002;39(suppl 1):S1-S266.
3. Kidney Disease Outcomes Quality Initiative (K/DOQI). K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43(suppl 1):11-13.
4. Luxton G; Caring for Australasians with Renal Impairment. The CARI Guidelines. Timing of referral of chronic kidney disease patients to nephrology services (adult). Nephrology (Carlton). 2010;15(suppl 1):S2-S11.
5. Jungers P, Massy Z, Nguyen-Khoa T, et al. Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant. 2001;16(12):2357-2364.
6. WK Bolton. Renal Physicians Association Clinical Practice Guidelines: appropriate patient preparation for renal replacement therapy: guide line number 3. J Am Soc Nephrol. 2003;14(5):1406-1410.
7. Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guidelines for the evaluation and management of chronic kidney disease. Kidney Int. 2013;3(suppl):1-150.
1. Levey AS, Inker LA. Definition and staging of chronic kidney disease in adults. UpToDate. www.uptodate.com/contents/definition-and-staging-of-chronic-kidney-disease-in-adults. Accessed January 29, 2020.
2. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J of Kidney Dis. 2002;39(suppl 1):S1-S266.
3. Kidney Disease Outcomes Quality Initiative (K/DOQI). K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43(suppl 1):11-13.
4. Luxton G; Caring for Australasians with Renal Impairment. The CARI Guidelines. Timing of referral of chronic kidney disease patients to nephrology services (adult). Nephrology (Carlton). 2010;15(suppl 1):S2-S11.
5. Jungers P, Massy Z, Nguyen-Khoa T, et al. Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant. 2001;16(12):2357-2364.
6. WK Bolton. Renal Physicians Association Clinical Practice Guidelines: appropriate patient preparation for renal replacement therapy: guide line number 3. J Am Soc Nephrol. 2003;14(5):1406-1410.
7. Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guidelines for the evaluation and management of chronic kidney disease. Kidney Int. 2013;3(suppl):1-150.
