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ate, and over twelve months as an early referral. Late phosphate binders calcium based or non calcium
referral of patients with CKD has numerous serious based.
consequences, including an increased mortality risk 6. Referral to a team consisting of a nephrologist,
(relative risk 1.68 at 1 yr), increased morbidity with renal dietitian, dialysis nurse, social worker and
lower use of antihypertensives, suboptimal manage- financial counselor allows time to establish the
ment of bone and mineral disorders, lower serum al- best treatment modality for the patient, develop
bumin (malnutrition), more use of temporary vascular financial support if needed and to allay the fears
access, longer hospital stay, and reduced access to of both patient and family.”
renal transplantation. The reasons for late referral

may be patient related or physician related. Psycho- 7. Prevention of recurrent infections.
logic factors such as denial of the need for dialysis, 8. Education to the patients and attendants regard-
advanced age, and low socioeconomic status with ing early transplant.
poor access to care may lead to late referral.
9. To prevent emergency dialysis which is associat-
Frequently the primary care provider will make the ed with poor outcome due to following reasons?
diagnosis of chronic kidney disease. Referral to a
nephrologist or other specialist for consultation or - jeopardizes the dialysis modality choice
co-management should be made after diagnosis - endangers ability to maintain prolonged vas-
under the following circumstances: a clinical action cular access
plan cannot be prepared based on the stage of the
disease, the prescribed evaluation of the patient can- - precludes psychological preparation of pa-
not be carried out, or the recommended treatment tients and family
cannot be carried out. These activities may not be - Frequently necessitates hospitalization for a
possible either because the appropriate tools are not catastrophic complex illness.
available or because the primary care physician does
not have the time or information needed to do so. In - Mortality associated with acute dialysis can be
general, patients with GFR <30 ml/min/1.73 m2 (CKD as high as 25%
Stages 4-5) should be referred to a nephrologist. In
case any I/V contrast has to be used for CT Scan/ Conclusions
MRA/Coronary interventions, the nephrologist opin- Ideally, after referral to the nephrologist for consul-
ion should be considered. tation, the patient will be referred back to his/ her
primary care physician (PCP) for further care. The
Early referral of CKD patients offers nephrologist should then develop a long-term man-
following advantages: agement plan in collaboration with the PCP to assist
in optimizing the patient’s care until there is further
1. A diligent search may reveal a potentially revers-
ible cause of renal failure. progression toward end-stage renal failure. In con-
clusion, the studies support that chronic kidney dis-
2. A number of measures may be implemented to ease patients fair better as their disease progress-
preserve the remaining renal function, e.g., good es toward end stage failure if they are referred to
control of blood pressure, glucose control in di- nephrologists for evaluation and co-management of
abetics, nutritional guidance, and avoidance of their care – ideally twelve months prior to the initiation
nephrotoxic drugs. of renal replacement therapy.
3. Upper extremity vessels may be preserved for References
placement of a native arterio-venous fistula, 1. ME Molitch et al.: Diabetic kidney disease: a KDIGO report, Kidney
which is the most reliable type of vascular ac- International advance online publication, 30 April 2014
cess. Dialysis grafts and catheters are sub-opti-
mal because of recurrent thrombosis and infec- 2. Diabetes Care 2014;37:2864–2883
tion. In addition, central venous catheters may 3. Global report on Diabetes by WHO 2016
irreversibly damage proximal veins precluding 4. V. Mohan - Prevalence of Diabetes and Hypertension in South Indian
future use of that extremity for vascular access. population – The Chennai Urban Rural Epidemiology study (CURES).
The Asian journal of Diabetology 2003;5:29-30.
4. Treatment of anemia with erythropoietin may sig- 5. Ref: Mani MK – Prevention of Chronic renal failure at the community
nificantly improve life quality. level. Kidney Int 2003;83:86-89)
5. Secondary hyperthyroidism may be treated with 6. Rajapurkar.M, Dabhi M, Burden of disease-prevalence and incidence of
renal disease in India. Clinical Nephropathy 2010;74:9-12

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