Referrals to nephrologists may not be warranted for many elderly patients with chronic kidney disease (CKD), who may be managed safely in the primary care setting, British researchers concluded based on a study of CKD patients aged 80 years and older.
“In our study, the elderly patients kept under regular surveillance in the nephrology clinic tended to have more advanced renal impairment and were likely to have rapid decline in kidney function,” Mark McClure, MBBS, and colleagues at Dorset County Hospital NHS Foundation Trust in Dorset, UK, wrote in an article published online ahead of print in the Clinical Kidney Journal. “This suggests that nephrologists were able to correctly identify the patients whom they predicted may require specialist renal input in terms of managing complications of CKD and provision of renal replacement therapy.”
In a retrospective study, Dr McClure’s team analyzed data from 124 patients aged 80 years or older (mean 84.4 years) referred to the nephrology outpatient clinic at their hospital. Of these, 115 had CKD stage 4 and 9 had CKD stage 5. Of the 124 patients, 66 were kept under regular follow-up in the clinic and 58 were discharged back to primary care. Patients kept under follow-up tended to have a lower median estimated glomerular filtration rate (eGFR) at referral than those discharged back to primary care (22 vs 26 mL/min/1.73 m2) and a significantly more rapid decline in mean eGFR over the following 7 years (1.58 vs 0.357 mL/min/1.73 m2).
In addition, significantly more patients in the follow-up group were started on erythropoietin (12 vs 3) and significantly more patients initiated dialysis (5 vs 0). In the follow-up group, 55 (83%) died, with a median time to death of 2.66 years. In the primary care group, 45 patients (78%) died, with a median time to death of 3.57 years.
The researchers said it is important to recognize that most elderly CKD patients ultimately will not require or desire renal replacement therapy and may be managed safely in the primary care setting.
“With increasing pressure on new-patient clinic slots, referral of a select group in which a specific intervention is being considered may be more appropriate,” they wrote. “Nephrologists also need to play their role to reduce the workload and should be encouraged to discharge such patients back to primary care after initial review in the clinic.”
Dr McClure’s group noted that awareness and detection of CKD in the United Kingdom has increased markedly over the past decade. Nationwide, they related, there has been a sustained increase in patients referred to nephrology clinics. “The increased referral have led to an older patient cohort, for whom specialty nephrology input is of questionable clinical benefit.”
McClure M, Jorna T, Wilkinson L, Taylor J. Elderly patients with chronic kidney disease: do they really need referral to the nephrology clinic? Clin Kidney J 2017; published online ahead of print.