The detection of advanced chronic kidney disease by surveillance of elevated plasma creatinines--a five-year experience

Abstract

The late referral of patients with advanced chronic renal failure to a nephrologist is multifactorial but also compromises the preparations for dialysis and is prejudicial to their survival on dialysis. Measures that prompt or hasten referral, will allow preparation for dialysis, control of complications and treatment of comorbid conditions. In June 2000, a programme was initiated to provide surveillance of plasma creatinines >300 micromol/L on all laboratory requests from general practitioners (GPs) and hospital clinicians in Ayrshire and Arran Health Board in southwest Scotland. Patients already known to the nephrologists were excluded. Results were regularly reviewed and further excluded if the creatinine fell or the patient died. For the remainder, a standard letter was sent to the requesting clinician suggesting renal referral if appropriate. This was to act as a prompt to the general practitioner or hospital clinician. For those referred over the 5-year period, the outcome was analysed in January 2007. In the first 5 years (June 2000-June 2005) letters were sent regarding 246 patients (median age 76). Fifty-three patients still had reversible ARF or died within 3 months of the letter; seven were already referred. The requesting clinician felt that referral was not appropriate in 56; 23 were being reviewed elsewhere. The programme has led to the referral of 50 patients to the renal service (and 3 to others) but in 54 cases no reply was received and the letter ignored. Of the 50 referred, 17 entered the dialysis programme, 13 of whom had definitive dialysis access (fistula or Tenckhoff catheter) at the start. After a period of outpatient review they have undergone a median of 21 months of dialysis. Over the 5-year period this programme has detected a cohort of patients who, in general, benefited from nephrological follow-up and dialysis. It may also act as a prompt to clinicians to refer more 'marginal' patients and thereby hasten future referral.