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Dr Arvind Gupta, Jaipur 24 November 2018

Physicians should be able to recognize alarming signs early in the course of the disease, and give appropriate treatment, or do timely referral to the Nephrologist. This can result in a substantial reduction in morbidity and mortality in patients with CKD.
Referral to the Nephrologist is recommended in the following situations: Stage 4 or 5 CKD from any cause, having eGFR of <30 mL/min/1.73 m²; Having ACR >30 mg/mmol or urine protein excretion of >500 mg/day, i.e., patient is having persistent significant albuminuria; A consistent decline in eGFR from a baseline of <60 mL/min/1.73 m2 (a decline of >5 mL/min/1.73 m2 over a 6-month period which is confirmed on at least three separate readings).
Referral to a specialist renal service or Nephrologist is suggested in the following situations: Glomerular hematuria with macroalbuminuria; CKD and hypertension difficult to control despite at least 3 antihypertensive agents.
Other criteria which are also required for referral to Nephrologist are: Acute deterioration of renal function, i.e., eGFR decline >25% in <1 month after exogenous factors being excluded; Renal progression, i.e., decline of eGFR of >5 mL/min/1.73 m2/year; Serum potassium >5.5 or <3.5 mEq/L; If the patient is suffering from anemia, i.e., Hb <10.5 g/dL with CKD and has a corrected transferrin saturation of more than 20% and serum ferritin >100 ng/mL.

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