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REVIEW

JNEPHROL 2010 ; 23 ( 04 ) : 399 - 407

www.sin-italy.org/jnonline – www.jnephrol.com

Criteria for referring patients with renal disease for nephrology consultation: a review of the literature

Carolyn De Coster 1,2 , Kevin McLaughlin 3 , Tom W. Noseworthy 2

1 Strategy & Performance, Alberta Health Services, Alberta - Canada 2 Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta - Canada 3 Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta - Canada

AbstrAct

Introduction: Referrals to nephrologists comprise not only patients with chronic kidney disease but also those with other nephrological conditions. There may be confusion about when to refer a patient to a neph- rologist. We conducted a literature review to identify preexisting priority-setting, triage or referral criteria developed to guide referrals from primary care to a nephrologist. Methods: Medline and Cochrane databases were searched (1997 to 2008) using search terms: referral, consultation, triage and a list of specified nephrologi- cal conditions. Abstracts were assessed by 2 review- ers using criteria to determine relevance. Citation and hand searches were done on papers selected for re- view; relevant Web sites were also consulted. Two re- viewers read all selected papers to determine if they met the objectives. One reviewer abstracted relevant data from each retained reference and compiled the results into a report, which was reviewed by 3 practic- ing nephrologists. Results: There were 18 retained papers, reports or Web sites; 4 of these were professional national guide- lines. All but 1 reference cited serum creatinine or esti- mated glomerular filtration rate as a criterion for refer- ral. Other referral criteria were proteinuria (8 sources), blood pressure (5 sources), electrolytes (3 sources) or hematuria (3 sources). There was inconsistency in re- ferral recommendations.

Conclusions: The differing advice identified in the literature results in confusion as to when patients should be referred to a nephrologist. Nephrologists, an already strained human resource, must prioritize requests for consultation using an undefined and no doubt inconsistent metric. Standardized, diagnosis- neutral criteria would benefit both primary care pro- viders and nephrologists.

Key words: Consultation, Glomerular filtration rate, Kid- ney diseases, Nephrology, Referral, Review

IntroductIon
IntroductIon

Demands on nephrology services are growing. There were 32,406 Canadians with end-stage kidney disease (ESKD) in 2005, compared with 18,000 in 1996, an average annual growth rate of 6.6% (1, 2). Patients with ESKD represent only about 2% of all patients with chronic kidney disease (CKD) (3), implying there were 1.6 million Canadians with CKD in 2005. Many of these are cared for by primary care physi- cians, but many are followed by a nephrologist or a multidis- ciplinary team. In 2008, there were 491 nephrologists prac- ticing in Canada (4), compared with 332 in 1998 (5). While patients with CKD comprise a substantial portion of the patients that nephrologists deal with, one must

© 2010 Società Italiana di Nefrologia - ISSN 1121-8428

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De Coster et al: Nephrology referral criteria review

remember that the scope of practice includes a variety of other nephrological conditions as well, such as acute infectious or inflammatory renal diseases, benign and ma- lignant tumors, recurring urolithiasis, electrolyte abnor- malities, hemodynamic imbalances and refractory hyper- tension (6). In addition, some systemic diseases such as the vasculitides or lupus erythematosus may have renal manifestations. Not all patients with CKD will progress to ESKD; however, for those who will progress, earlier referral leads to im- proved outcomes (3, 5, 7, 8). Many patients can and should be managed by their primary care providers, but there may be uncertainty about when to refer. We conducted a litera- ture review to assess whether there were uniform criteria to guide referrals from primary care to specialist care/con- sultation usually provided by a nephrologist. Furthermore we were interested to know if there were different levels of urgency or priority in referral criteria. This paper describes the findings of the review.

Methods
Methods

The methods used were similar to standard methods used in systematic reviews, with some modifications (9-11). We allowed for the fact that we might uncover guidelines for prioritizing referrals used by individual facilities on Web sites or in letters to the editor. Therefore, we erred on the side of inclusiveness and followed up any papers that seemed potentially relevant, regardless of quality. We searched Medline and Cochrane databases from 1997 to 2008, English only, using the terms referral, triage or con- sultation AND at least 1 from a list of nephrology-specific search terms (Appendix). The list had been reviewed by a nephrologist and family physician and included terms such as glomerulonephritis, diabetic nephropathies, polycystic kidney diseases, proteinuria, renal dialysis, elevated BUN and Alport syndrome. The search yielded 655 abstracts and titles (Fig. 1). Criteria for the selection of relevant abstracts were devel- oped, tested and revised in an iterative process. All ab- stracts were reviewed by 2 reviewers and rated as Yes (Y), No (N) or possible (Q). Papers rated as Y/Q, Q/Q or Y/N were reviewed by a third reviewer. At the end of this pro- cess, 65 papers had been identified for retrieval. The crite- ria for inclusion/exclusion were revised further, and the 65 abstracts were assessed again by 3 reviewers. Twenty-four papers were subsequently retrieved and read in full by 2 re- viewers; 13 of these papers were retained. Citation search- es and manual reference list searches were also conducted on papers that were selected. As well relevant Web sites

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De Coster et al: Nephrology referral criteria review remember that the scope of practice includes a

Fig. 1 - Diagram of literature search and retention strategy for nephrology referral review.

were consulted, including those of the Canadian Society of Nephrology; Kidney Disease: Improving Global Outcomes; Caring for Australians with Renal Impairment; European Best Practice Guidelines; and the Renal Association (UK). Five more citations were identified and retained. One re- viewer abstracted the relevant data from each retained ref- erence and compiled the results. The resulting report was then reviewed by 3 practising nephrologists.

results
results

Table I identifies the 18 retained papers, reports or Web sites (3, 5, 7, 8, 12-24). Four of the identified citations are professional national guidelines from Canada (18), the United States (16), the United Kingdom (15) or Australia (21). The largest number of citations were from the United States (8 citations), followed by Canada (4 citations), the United Kingdom (3 citations), other European countries (2 citations) and Australia (1 citation). Almost all of the crite- ria for referral included mention of either serum creatinine or estimated glomerular filtration rate (eGFR). Criteria that were sometimes, but not universally, included were mea- sure of proteinuria (8 sources), blood pressure (5 sources), electrolytes (3 sources) or hematuria (3 sources). Other criteria were anemia, presence of diabetes, the need for a renal biopsy, problems with management or primary care provider concern.

JNEPHROL 2010 ; 23 ( 04 ) : 399 - 407

TABLE I

SOURCES FOR CRITERIA FOR REFERRAL TO NEPHROLOGY

Author, source, year

Country

GFRor SeCR

Proteinuria

Electrolytes

Hematuria

BP

Other

Bakris. Postgrad Med 2003 (12)

US

UK

Canada

US

Burden and Tomson. Clin Med 2005 (13)*

Canadian Society of Nephrology. Can Fam Physician 2000 (7) Crooks. Southern California Kaiser

Permanente (PowerPoint presentation)

2005**

Jenkins et al. Nurs Times 2007 (14)*

UK

UK

US

Levin. Nephrol Dial Transplant 2001 (17)

Canada

Canada

Canada

Joint Specialty Committee on Renal Medicine of Royal College of Physicians & the Renal Association & the Royal

College of General Practitioners. Royal College of Physicians 2006 (15) National Kidney Foundation: Kidney Dis- ease Outcomes Quality Initiative (KDOQI)

Web site 2002 (16)

Levin and Mendelssohn. Canadian

 

Society of Nephrology 2006 (18) Mendelssohn et al. CMAJ 1999 (5)

Obrador and Pereira. Am J Kidney Dis

US

  • 1998 (8)

Schwartz and Textor. Mayo Clin Proc

US

  • 2006 (19)

Snyder and Pendergraph. Am Fam Phy-

US

US

sician 2005 (20) St Peter et al. Am J Kidney Dis 2003 (3)

Thomas. Nephrology 2007 (21)

Australia

Thorp and Eastman, Am J Manag Care

US

  • 2004 (22)

Van Biesen et al. Nephrol Dial Transplant

Belgium
2006

(23)

Switzerland,

Wauters et al. Nephrol Dial Transplant

Belgium, UK,
2005

(24)

Germany

Dots indicate that this criterion was included in the reference cited. BP = blood pressure; GFR= decrease in glomerular filtration rate; SeCR = increase in serum creatinine. *Referenced the UK Joint Specialty Guidelines. **Crooks P. GFR implementation & CKD program at Southern California Kaiser Permanente. October 4, 2005 [powerpoint presentation].

De Coster et al: Nephrology referral criteria review

TABLE II

SPECIFIC RECOMMENDATIONS FOR REFERRAL OF PATIENTS WITH REDUCED KIDNEY FUNCTION, EXCLUDING

ACUTE RENAL FAILURE

Author, year

Note

GFRor SeCR

Proteinuria

Electrolytes,

Other

 

hematuria,

BP

Bakris, 2003 (12)

Referral for

SeCr 1.5 mg/dL

Threefold-to-

diabetics with

fourfold increase

diabetic

in albuminuria in 6

nephropathy

months Cannot reduce albuminuria by 30% with good BP control

Burden and Tomson,

See Royal College

2005

(13)

(UK) 2006

Canadian Society of Nephrology, 2000 (7)

 

Established progressively increasing SeCr OR SeCr 300 µmol/L

 

Crooks, 2005

eGFR <30 ml/min per

>1,000 mg/day

Hypertension hard

Suspected

 

1.73

m 2

to manage

EPO-deficiency

 

anemia

Jenkins et al, 2007

See Royal College

(14)

(UK) 2006

Royal College (UK),

 

eGFR <30

PCR >45

K + 6-7 mmol/L*

Suspected

2006

(15)

mL/min/1.73 m 2 * eGFR <60 ml/min per

mg/mmol Proteinuria with

Malignant hypertension*

systemic illness, e.g., SLE*

 

1.73

m 2

edema and low

Abnormal K + , Ca 2+ ,

Unexplained

Fall of GFR >20% associated with use of ACEIs or ARBs 15% fall GFR in 12 months

serum albumin* Proteinuria + he- maturia Diabetes w. increasing protei- nuria

PO 3- BP >150/90 on 3 agents Microscopic hematuria Unexplained mac- roscopic hematuria

anemia (Hgb <11 g%) PTH >70 ng/L (7.7 pmol/L)

KDOQI, 2002 (16)

 

eGFR <30 ml/min per

 
 

1.73

m 2

Levin, 2001 (17)

Advises timely referral but no criteria

Levin and

 

eGFR <30 ml/min per

Persistent dipstick

Progressive loss

Mendelssohn,

1.73

m 2

proteinuria OR

of kidney

2006

(18)

PCR >100 mg/ mmol or ACR >60 mg/mmol

function Problems w. management of BP, meds or other

JNEPHROL 2010 ; 23 ( 04 ) : 399 - 407

TABLE II

CONTINUED

Author, year

Note

GFRor SeCR

Proteinuria

Electrolytes,

Other

 

hematuria,

BP

Mendelssohn et al,

SeCr 300 µmol/L

1999

(5)

Obrador and Pereira,

SeCr 1.5 mg/dL in

1998

(8)

women or 2.0 mg/dL in men

Schwartz and Textor,

Editorial

eGFR <30 ml/min per

2006

(19)

  • 1.73 m 2

Snyder and Pender-

eGFR <60 ml/min per

Renal biopsy,

graph, 2005 (20)

  • 1.73 m 2

help w. manage- ment

St. Peter et al, 2003

eGFR <60 ml/min per

(3)

  • 1.73 m 2

Thomas, 2007 (21)

eGFR <30 ml/min per

>1 g/24 hours

Uncontrolled

Anemia (<110

  • 1.73 m 2

hypertension

g/L)

 

Significant

comorbid illness

Thorp and Eastman,

eGFR 30-60

2004

(22)

ml/min per 1.73 m 2

Van Biesen et al,

eGFR 30-60 ml/min

2006

(23)

per 1.73 m 2

Wauters et al, 2005

eGFR <25-30

Established

(24)

ml/min per 1.73 m 2

microalbuminuria

20% decrease in GFR

in diabetics

ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker; ACR = albumin to creatinine ratio; BP = blood pressure; Ca 2+ = serum calcium; eGFR = estimated glomerular filtration rate; EPO = erythropoietin; Hgb = hemoglobin; K + = serum potassium; PCR = protein to creatinine ratio; PTH = parathyroid hormone; PO 3 = serum phosphate; SeCr = serum creatinine; SLE = systemic lupus erythematosus. *Indication for urgent referral.

Table II describes in more detail criteria for referral of pa- tients with reduced kidney function, excluding patients with acute renal failure. The most common criterion is ei- ther serum creatinine or eGFR; since 2000, eGFR is used more commonly than serum creatinine. CKD is commonly divided into 5 stages, based on 2 readings from 1 to 3 months apart: from stage 1 to stage 5, the associated eGFRs are >90, 60 to 89, 30 to 59, 15-29 and <15 ml/min

per 1.73 m 2 , respectively. GFR estimates alone are insuffi- cient for a diagnosis of CKD stage 1 and 2; other evidence of kidney damage must be present (5, 13, 16, 18). Other evidence for kidney damage includes persistent microal- buminuria, proteinuria or hematuria, structural abnormali- ties of the kidneys or biopsy-proven glomerulonephritis (13). Sources conflicted on whether referral should occur at CKD stage 3 (3, 13, 21) or stage 4 (7, 22, 25).

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De Coster et al: Nephrology referral criteria review

Proteinuria is a hallmark of many renal disorders (26). Con- sequently, several sources cited proteinuria or albuminuria as a criterion for referral. The UK guidelines recommend referral when the protein to creatinine ratio (PCR) is more than 45 mg/mmol, which is equivalent to an albumin to cre- atinine ratio (ACR) of more than 30 mg/mmol or a urinary protein excretion of about 0.5 g/24 hours (15). The UK val- ues are lower than those recommended by the Canadian Society of Nephrology; it advises referral with persistent dipstick proteinuria, PCR >100 mg/mmol or ACR >60 mg/ mmol. The Canadian values are similar to those recom- mended by Crooks (United States) and Thomas (Austra- lia) (21) who used protein excretion of more than 1 g in 24 hours to define proteinuria that should be referred. Diabetes is a leading cause of CKD. It is estimated that 40% of all diabetics in the United States have CKD, com- pared with 15% of nondiabetics, and Canadian estimates are that 35% of new ESKD patients have diabetes as the primary cause (27, 28). Three sources suggested that dia- betic patients be referred based on proteinuria: Bakris ad- vised referral when there had been a threefold-to-fourfold increase in albuminuria in 6 months or an inability to re- duce albuminuria by 30% even with effective control of hypertension (12); Wauters et al suggested referral with established microalbuminuria (24) and the UK guidelines recommended referral when proteinuria is increasing. Mi- croalbuminuria may be defined as 30 to 300 mg urinary albumin per 24 hours, whereas macroalbuminuria is more than 300 mg urinary albumin per 24 hours (29). Only the UK guidelines made specific reference to elec- trolytes as a reason for referral, stating that a serum po- tassium above 7.0 mmol/L required an emergency con- sultation with a nephrologist, serum potassium between 6.0 and 7.0 mmol/L required an urgent consultation and elevated levels of potassium, calcium or phosphate in a stage 3 CKD patient requires routine referral. Hematuria was also mentioned only in the UK guidelines. Refractory hypertension was identified in 4 sources (15, 18, 21). The UK guidelines were the most specific, advising emergency referral for malignant hypertension and routine referral for refractory hypertension, defined as blood pressure (BP) of 150/90 mm Hg despite therapy with 3 drugs from different classes. Anemia as a reason for referral was identified by 3 sources (15, 21).

dIscussIon
dIscussIon

Our review demonstrated that there is a lack of consistency in referral recommendations, and furthermore, that many guidelines mention only eGFR or serum creatinine as a refer-

404

ral criterion. The UK guidelines provided the most compre- hensive description of when patients should be referred and included 3 urgency bands (15). These guidelines described not only absolute values of eGFR, but also a change in eGFR that should prompt referral. Other criteria included protei- nuria, electrolytes, hypertension, hematuria, parathyroid hormone, anemia and systemic illness. They also outline the types of patients who can be managed by the primary care provider, possibly with advice from a nephrologist. No other sources included that level of detail. The Australian guide- lines cite eGFR, proteinuria, hypertension, anemia and co- morbid illness (21). The Canadian guidelines include eGFR, proteinuria and problems with management of hypertension, medications or other issues (18). These 3 guidelines are the most detailed, whereas several other sources focused only on eGFR or serum creatinine as the criterion for referral (3, 8, 16, 19, 22, 23). It is worth noting that different recalcula- tion methods can yield eGFR results varying by as much as 85% (23). Sources conflict on whether referral should occur at CKD stage 3 (3, 13, 21) or stage 4 (7, 22, 25). Earlier referral has the potential to improve the outcomes of comorbid dis- eases; decrease the number of complications such as ane- mia, cardiovascular disease, diabetes, hypertension and malnutrition; delay the onset of end-stage kidney disease; improve patient survival; reduce the use of temporary vas- cular access devices; optimize the patient’s biochemical, physical and psychological state for the initiation of dialysis; improve vocational outcomes and reduce hospital stays (3, 5, 7, 8). The differential impact on nephrologists between referral at CKD stage 3 or 4 is quite substantial; St. Peter et al reported that 39% of patients with CKD are in stage 3, whereas only 2% are in stage 4, or 700,000 versus 64,000 patients, using 2005 estimates of CKD in Canada (3). The Canadian Society of Nephrology recommends referral at stage 4 (7, 25). Two sources also stated that a decrease in GFR of 15% (15) or 20% (30) should prompt referral. While earlier referral has been recommended for improved outcomes, earlier referral coupled with longer survival of patients may overwhelm nephrological services (3, 7, 23). Therefore joint management of patients with CKD has been suggested (3, 7, 17, 18, 20, 22). Multidisciplinary renal teams can provide patients with better information and education, monitoring and follow-up, and also create opportunities for discussion groups and contacts with other ESKD patients (31). A survey found that most Canadian nephrologists uti- lize such clinics routinely (32). While the majority of patients were referred when they are in CKD stage 4, two thirds of nephrologists surveyed said they would prefer referral while patients were still in stage 3 (32).

JNEPHROL 2010 ; 23 ( 04 ) : 399 - 407

Wauters et al proposed a timetable for sharing the care of CKD patients, progressing from a single consultation to es- tablish a diagnosis and suggest a follow-up plan, to annual appointments with the nephrologist once CKD has been di- agnosed but does not progress to ESKD, to management of the patient once GFR is <30 ml/min per 1.73 m 2 (24). As a referral criterion, there was also somewhat conflicting advice regarding proteinuria, with the UK guidelines sug- gesting referral at approximately half the level suggested by the Canadian and Australian guidelines. How proteinu- ria is to be measured is an additional source of potential confusion: dipstick proteinuria, protein to creatinine ratios, albumin to creatinine ratios, microalbuminuria, albuminuria and 24-hour urinary protein were all mentioned. The differing advice identified in the literature results in confusion as to when patients should be referred to a nephrologist. Nephrologists on the other hand must as- sess requests for consultation and prioritize patients us- ing some sort of undefined metric and one that no doubt varies among individual nephrologists. Development of a prioritization referral tool would benefit both primary care providers and nephrologists. For primary care providers, the tool would help to standardize the referral process, reducing the frustration of multiple forms and referral re- quirements. For nephrologists, required information will be available; studies show that 50% or more of referral letters are missing information that specialists require (33- 37). Referrals would be prioritized in order of urgency in a transparent process. To this end, a clinical panel compris- ing nephrologists and primary care providers, informed by this literature review, are completing the work of for- mulating a nephrology priority referral score, and plan to test the reliability and validity of the tool for prioritizing patients referred to nephrologists.

AppendIx
AppendIx

Nephrological conditions searched

Acute interstitial nephritis (AIN) Acute kidney failure Acute kidney injury Acute renal failure Acute renal insufficiency Acute tubular necrosis (ATN) Alport syndrome Amyloidosis ANCA vasculitis Anti-GBM disease Bladder cancer

Bladder infection(s) Bladder neoplasm(s) BUN creatinine ratio Chronic interstitial nephritis (CIN) Chronic kidney disease(s) Chronic kidney failure Chronic renal insufficiency Contrast nephropathy Crescentic glomerulonephritis Cystic kidney diseases/disorders Cystitis Diabetic nephropathies Dialysis Electrolyte disorders Electrolyte disorders Elevated BUN Elevated creatinine End stage renal disease (ESRD) Fanconi syndrome Fibromuscular dysplasia (FMD) Focal segmental glomerulosclerosis Glomerular diseases Glomerulonephritis Glomerulosclerosis Glomerulotherapy Goodpasture’s syndrome Hemodialysis Hematuria Hemodiafiltration Hemodialysis Hemofiltration Hepatorenal syndrome Hydronephrosis Hypercalcemia Hyperkalemia Hypernatremia Hypertensive nephrosclerosis Hypocalcemia Hypokalemia Hypomagnesemia Hyponatremia Hypophosphatemia IgA nephropathy Kidney calculi Kidney cancer Kidney cortex necrosis Kidney cysts Kidney damage Kidney diseases Kidney failure Kidney infection(s) Kidney neoplasms

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De Coster et al: Nephrology referral criteria review

Kidney stones Kidney transplantation Kidney tubular necrosis Kidney(s) Light chain cast nephropathy Lupus nephritis Membranous nephropathy Membranoproliferative glomerulonephritis Mesangioproliferative Mesoblastic nephroma Microalbuminuria Microscopic polyangiitis Minimal change disease Multiple myeloma Nephritic syndrome Nephritis Nephrocalcinosis Nephrolithiasis Nephrologist(s) Nephrology Nephropathy Nephrosclerosis Nephrosis Nephrotic syndrome Paediatric nephrology Painful bladder syndrome Pancreas transplantation Pediatric nephrology Perinephritis Peritoneal dialysis Polycystic kidney Polycystic kidney diseases Post infectious glomerulonephritis Prostate enlargement Prostatitis Proteinuria Pyelitis

Pyelocystitis Pyelonephritis Renal Renal artery obstruction Renal artery stenosis Renal cell carcinoma Renal cystic disorders Renal diabetes Renal dialysis Renal diseases/disorders Renal failure Renal insufficiency Renal replacement therapy Renal transplantation Renal tuberculosis Thin basement membrane disease Uremia Urinary tract infections Wegener granulomatosis Wilms tumor Wolfram syndrome

Financial support: This work was funded by Alberta Health and Wellness – Access to Medical Services Grant.

Conflict of interest statement: None of the authors has a financial or other relationship that might lead to a conflict of interest with respect to the research.

Address for correspondence:

Carolyn De Coster, PhD, RN Senior Researcher Alberta Health Services 4520 – 16th Avenue NW Calgary, Alberta T3B 0M6, Canada Carolyn.DeCoster@albertahealthservices.ca

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Received: July 30, 2009 Accepted: August 05, 2009

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