Published in:
01-06-2009 | Guidelines
Chapter 14. Timing for referral of CKD patients to nephrologists
Published in: Clinical and Experimental Nephrology | Issue 3/2009
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Individuals found to have abnormalities in the dipstick urinalysis test or in eGFR at health checkups or any other occasion are best referred to a primary care clinic as soon as possible.
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Urinalysis, including proteinuria and hematuria, should be re-checked; a person with proteinuria should be evaluated for the amount of urinary protein as a g/g creatinine ratio by simultaneous measurement of creatinine and protein concentrations in a spot urine. All patients should be re-evaluated for renal function as eGFR with simultaneous determination of serum creatinine.
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If fulfilling any of the three criteria listed below, CKD patients should be referred to a nephrologist and thereafter managed cooperatively by a nephrologist and a primary care physician:
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Urinary protein amount ≥0.5 g/g creatinine or 2+ by dipstick test
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eGFR <50 mL/min/1.73 m 2
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Positive for both proteinuria and occult blood (1+ or greater) by dipstick test
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CKD patients at stage 1–3 basically should be treated by the primary care physician. However, patients with rapidly progressive renal disease or any problems with blood pressure or blood glucose control should consult with nephrologists or diabetologists for assessment of therapeutic plans.
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All patients found to have abnormal urinalysis tests at health checkups should be referred to a primary care clinic as soon as possible. Crucial points for early detection and early intervention are recruitment of the individuals with urinary abnormalities to the medical system and selection of the patients to be managed at the appropriate medical system. Therefore, urinalysis at the health checkup is an important initial step for this strategy.
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The primary care physician should repeatedly check urinalysis (proteinuria and hematuria by urine dipstick test, measurement of protein, as well as creatinine concentrations in a urine specimen for estimation of urinary protein excretion as the urine protein/creatinine ratio), and the serum creatinine level to confirm the CKD stage in the referred patient. Then, risk factors for CKD, such as diabetes, hypertension, dyslipidemia, obesity, smoking, and anemia, should be evaluated and, if detected, treated and corrected.
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The criteria for a primary care physician to recommend referral of a patient to a nephrologist are as follows:
(1)
High amount of urinary protein (heavy proteinuria): A urinary protein/creatinine ratio ≥0.5 g/g creatinine is possibly a predictor for a rapid decline in renal function, so that specific medical examinations, including renal biopsy by nephrologists, are recommended in this case. In clinical practice, proteinuria ≥2+ by dipstick test is equivalent to a urinary protein/creatinine ratio ≥0.5 g/g creatinine.
(2)
Coincidence of proteinuria ≥1+ and hematuria (occult blood) ≥1+: Coincidence of proteinuria ≥1+ and hematuria (occult blood) ≥1+ by urine dipstick test may be a poor prognostic sign; thus, it is considered as a criterion for referral to a nephrologist.
(3)
eGFR <50 mL/min/1.73 m 2 : The number of persons with eGFR <50 mL/min/1.73 m2 in the general Japanese adult population aged 20 years or older is estimated to be 4,180,000 (4.1%); these adults are expected to show a rapid decline in renal function in the future based on an epidemiological study performed by JSN and thus should be referred to nephrologists as therapeutic targets.
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Therapeutic plans are established by the nephrologists once the patients are referred. Thereafter, the primary care physicians and the nephrologists should cooperate with each other to provide good medical management of individual patients for better prognosis.
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A formula for a proposed cooperative system for the management of CKD patients is shown in Fig. 14-1. Persons found to have proteinuria or hematuria at a health checkup should necessarily be referred to a primary care physician for further evaluation. Then, primary care physicians should refer the person according to the criteria mentioned above, based on the results of re-examination of urinalysis and eGFR, to a nephrologist as soon as possible. Nephrologists perform specific diagnostic procedures, including renal biopsy, based on which they should plan patient care and perform therapeutic procedures in collaboration with primary care physicians.Fig. 14-1A proposal of collaborative CKD management system between primary care physicians and nephrologists×
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The patients who do not fit into any of the three referral criteria as mentioned above (urinary protein/creatinine ratio <0.5 g/g creatinine, solitary 1+ proteinuria, solitary 1+ urinary occult blood, or eGFR ≥50 ml/min/1.73 m2) should be treated by primary care physicians for better modification of lifestyle, control of blood pressure and/or blood glucose according to the clinical practice guidebook of CKD.
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For implementation of such a local medical collaborative system as mentioned above, improvements in the knowledge and enthusiasm of medical staff as well as medical environments are critical.
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A list of nephrologists (board-certified nephrologists of the Japanese Society of Nephrology) is presented on the home page of the Japanese Society of Nephrology http://www.jsn.or.jp.