Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease

Chronic Kidney Disease (CKD) and kidney failure is a global health problem associated with morbidity, mortality and health care costs with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determine different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is < 30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead over-diagnosis of CKD in elderly and under-diagnosis of CKD in young patients and contributes to unfair referral of CKD patients to a kidney specialist. Non-age adapted recommendations contributes to unnecessary referral in very elderly with mild disease where risk of death consistently exceeds the risk of progression to kidney failure and on the other hand ignore the possibility of effective interventions of young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers which are possibly unable to accomplish optimally guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically leaded to focus referral on advanced CKD stages preparing kidney replacement, but the need for hasty referral to at nephrologist because of urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move towards reducing the kidney failure burden. Kidney Failure Risk Equation (KFRE) and its potential value is a novel tool that can guide wiser nephrology referrals and impact patient volumes.