Characteristics of outpatients referred for a first consultation with a nephrologist: impact of different guidelines

Abstract

Introduction Chronic kidney disease (CKD) affects > 10% of the population but not all CKD patients require referral to a nephrologist. Various recommendations for referral to nephrologists are proposed worldwide. We examined the profile of French patients consulting a nephrologist for the first time and compared these characteristics with the recommendations of the International Kidney Disease: Improving Global Outcomes (KDIGO), the French "Haute Autorité de Santé" (HAS), and the Canadian Kidney Failure Risk Equation (KFRE). Methods University Hospital electronic medical records were used to study patients referred for consultation with a nephrologist for the first time from 2016 to 2018. Patient characteristics (age, sex, diabetic status, estimated glomerular filtration rate (eGFR) and urine protein-to-creatinine ratio (PCR), etiology reported by the nephrologist) and 1-year patient follow-up were analyzed and compared with the KDIGO, HAS and Canadian-KFRE recommendations for referral to a nephrologist. The stages were defined according to the KDIGO classification, based upon kidney function and proteinuria. ResultsThe 1,547 included patients had a median age of 71 [61-79] years with 56% males and 37% with diabetes. The main nephropathies were vascular (40%) and glomerular (20%). The KDIGO classification revealed 30%, 47%, 19%, 4% stages G1-2 to G5, and 50%, 22%, 28% stages A1-A3, respectively. According to KDIGO, HAS and KFRE scores, nephrologist referral was indicated for 42%, 57% and 80% of patients respectively, with poor agreement between recommendations. Furthermore, we observed 890 (57%) patients with an eGFR> 30 ml/min and a urine protein to creatinine ratio 0.5 g/g, mostly aged over 65 years (67%); 40% were diabetic, and 57% had a eGFR > 45 ml/min/1.73m 2 , 56% were diagnosed as vascular nephropathy and 11% with unknown nephropathy. Conclusion These results underline the importance of better identifying patients for referral to a nephrologist and informing general practitioners. Other referral criteria (age and etiology of the nephropathy) are debatable.

Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease

“…Different recommendations for referral (KDIGO, NICE, others) do not help clinicians [ 84 ], who need standardization of criteria. Consensus is required to generate simple and optimum updated referral criteria for widespread use.…”

Can Kidney Care Be Sustainable?

“…However, the current guidelines on nephrology referral indicate that our intervention should be limited to patients with relevant proteinuria or CKD stages 3b-4. 9 This can hardly be defined as early. This policy leaves out progressive diseases in which early actions may be beneficial.…”

Qualitative approach to better understand the trajectory of patients with early and moderate stage CKD

“…Although the involvement of primary care providers in early-stage management seems essential to early diagnosis to preserve the nephron reserve, co-management with nephrologists remains complex in practice [ 4 ]. Recent studies show that in the field, referral of patients to nephrologists does not correspond to the recommendations [ 5 ] and the lack of secondary care providers will not allow the recommendations to be applied [ 6 ]. These difficulties encountered by primary care providers raise a number of questions that need to be explored and understood: What are their representations of early-stage renal disease?…”