Referrals and patient care

Referral to specialist services

The nephrological community recommends referral to specialist kidney care services for people with CKD in the following circumstances:

  • AKI or abrupt sustained fall in GFR;
  • GFR <30 ml/min/1.73 m2 (GFR categories G4-G5);
  • a consistent finding of significant albuminuria (ACR ≥300 mg/g [≥30 mg/mmol] or AER ≥300 mg/24 hours, approximately equivalent to PCR ≥500 mg/g [≥50 mg/mmol] or PER ≥500 mg/24 hours);
  • progression of CKD;
  • urinary red cell casts, RBC 420 per high power field sustained and not readily explained;
  • CKD and hypertension refractory to treatment with 4 or more antihypertensive agents;
  • persistent abnormalities of serum potassium;
  • recurrent or extensive nephrolithiasis;
  • hereditary kidney disease.1

In summary, a good coordination between the nephrology team and the primary care physician will:

  • slow down the rate of progression of kidney disease.
  • improve cardiovascular morbidity and mortality associated with kidney failure.
  • suitably prepare for entry into dialysis if it is needed and for transplantation listing (pre-emptive)
  • reduce hospital admissions and healthcare costs associated with CKD.

Patient care

The nephrological community recommends that people with progressive CKD should be managed in a multidisciplinary care setting.1

The multidisciplinary team should include or have access to dietary counselling, education, and counselling about different RRT modalities, transplant options, vascular access surgery, and ethical, psychological, and social care.1

Patient communication: information, awareness and responsibility

As most healthcare professionals do not screen routinely for the presence of kidney injury in these high risk conditions many patients are unaware that they may be affected and are potentially at risk of developing progression of kidney disease and consequent cardiovascular complications.2

It is therefore important that education strategies for patients and families are put in place: The aim is that the CKD patient assumes responsibility for his own kidney health.2

A high priority has to be the provision of information to patients on how to minimise risks and complications of progressive kidney damage: e.g. eat healthy, do regular exercise, control stress levels, no smoking, good control of blood pressure and blood sugar as well as correct dose of medication.2

Ideally, patients in advanced stages of their disease should be adequately prepared for dialysis. Therefore, a timely referral to nephrology is crucial, since an early referral and the quality of pre-dialysis care have been strongly correlated to the outcome after beginning RRT.1