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Criteria for referring patients with renal disease for nephrology consultation: a review of the literature.

INTRODUCTION
Referrals to nephrologists comprise not only patients with chronic kidney disease but also those with other nephrological conditions. There may be confusion about when to refer a patient to a nephrologist. We conducted a literature review to identify preexisting priority-setting, triage or referral criteria developed to guide referrals from primary care to a nephrologist.


METHODS
Medline and Cochrane databases were searched (1997 to 2008) using search terms: referral, consultation, triage and a list of specified nephrological conditions. Abstracts were assessed by 2 reviewers using criteria to determine relevance. Citation and hand searches were done on papers selected for review; relevant Web sites were also consulted. Two reviewers read all selected papers to determine if they met the objectives. One reviewer abstracted relevant data from each retained reference and compiled the results into a report, which was reviewed by 3 practicing nephrologists.


RESULTS
There were 18 retained papers, reports or Web sites; 4 of these were professional national guidelines. All but 1 reference cited serum creatinine or estimated glomerular filtration rate as a criterion for referral. Other referral criteria were proteinuria (8 sources), blood pressure (5 sources), electrolytes (3 sources) or hematuria (3 sources). There was inconsistency in referral recommendations.


CONCLUSIONS
The differing advice identified in the literature results in confusion as to when patients should be referred to a nephrologist. Nephrologists, an already strained human resource, must prioritize requests for consultation using an undefined and no doubt inconsistent metric. Standardized, diagnosis-neutral criteria would benefit both primary care providers and nephrologists.