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 ; the great majority of these
people will never develop established renal failure , 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 ,
and are available online at http://www.renal.org/eGFR/eguide.html. Their
use is endorsed by the National Service Framework for Renal Services .
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 . 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.
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Care. London: Department of Health, 2005:1-30.
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Competing interests: No competing interests