Intended for healthcare professionals

Clinical Review

Prevention and early detection of vascular complications of diabetes

BMJ 2006; 333 doi: (Published 31 August 2006) Cite this as: BMJ 2006;333:475

indications for referral to a Nephrology department are incorrect and unachievable

Marshall and Flyvbjerg state (Box 6) that patients should be referred
to a nephrology department, if possible, when GFR <60 ml/min/1.73 m2.
If implemented across the UK, this would completely overwhelm nephrology
departments while adding little or no value to the care of the great
majority of patients referred. Around 4.3% of the adult population has a
GFR between 30 and 60 ml/min/1.73 m2 [1]; the great majority of these
people will never develop established renal failure [2], nor will they
have complications of kidney disease requiring specialist treatment. UK
guidelines for the identification, management and referral of chronic
kidney disease in adults have recently been developed by a
multiprofessional group including representatives from Diabetes UK [3],
and are available online at Their
use is endorsed by the National Service Framework for Renal Services [4].
These suggest that diabetic patients with stage 3 Chronic Kidney Disease
(estimated GFR 30-59 ml/min/1.73 m2) require referral only if additional
conditions apply, including renal osteodystrophy, renal anaemia, or
suspected atherosclerotic renal artery stenosis; haematuria; and worsening
clinical proteinuria in the absence of diabetic retinopathy.

Late referral of patients requiring renal replacement therapy is
harmful, and around 1 in 5 of diabetic patients starting RRT in the UK is
referred with less than 4 months of the start of RRT [5]. It is critically
important that such patients are seen coming and referred in a timely
manner. However, referring all patients with reduced GFR is not the right
way to achieve this.

1. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of
chronic kidney disease and decreased kidney function in the adult US
population: Third National Health and Nutrition Examination Survey. Am J
Kidney Dis 2003;41(1):1-12.

2. Keith DS, Nichols GA, Gullion CM, Brown JB, Smith DH. Longitudinal
follow-up and outcomes among a population with chronic kidney disease in a
large managed care organization. Arch Intern Med 2004;164(6):659-63.

3. Joint Specialty Committee for Renal disease of the Royal College of
Physicians of London and the Renal Association. Chronic kidney disease in
adults: UK guidelines for Identification, Management, and Referral: Royal
College of Physicians of London, 2006.

4. Department of Health. National Service Framework for Renal Services.
Part Two: Chronic Kidney Disease, Acute Renal Failure, and End of Life
Care. London: Department of Health, 2005:1-30.

5. Ansell D, Feest T, Rao R, Williams A, Winearls CG (eds). The Renal
Association UK Renal Registry: The Eighth Annual Report, 2005.

Competing interests:
None declared

Competing interests: No competing interests

18 September 2006
Charles R Tomson
Consultant Nephrologist
Department of Renal Medicine, Southmead Hospital, Bristol BS10 5NB