Unreferred chronic kidney disease: a longitudinal study

Chronic kidney disease (CKD) is a major health problem. A better understanding of the epidemiological characteristics of the different stages of CKD and the associated adverse outcomes is needed to establish and implement appropriate management strategies.

A serum creatinine (SCr) level of 2.03 mg/dL or greater (> or =180 micromol/L) in men and 1.53 mg/dL or greater (> or =135 micromol/L) in women was used to identify patients with moderate to severe CKD in a predominantly Caucasian area of the United Kingdom. Patients who were unknown to renal services were identified and followed up to establish survival, rate of referral, and change in glomerular filtration rate (GFR).

The prevalence of CKD defined by SCr cutoff values was 5,554 per million population (pmp). Median calculated GFR of the cohort was 28.5 mL/min/1.73 m2 (range, 4.1 to 42.8 mL/min/1.73 m2), and median age was 83 years (range, 18 to 103 years). A total of 84.8% of patients were unknown to renal services. During a mean follow-up of 31.3 months, 8.1% of patients were referred. Median survival of the unreferred population was 28.1 months. Cardiovascular disease, cancer, and infection were the most common causes of death. Male sex, low GFR, and nonreferral were associated with poor outcome. The majority of unreferred patients had stable renal function. The incidence of new unreferred CKD during the first year of follow-up was 2,435 pmp, such that the prevalence remained stable at 4,910 pmp. Significant anemia (hemoglobin < 11 g/dL [<110 g/L]) was seen in 27.5% of the unreferred cohort.

Referral of all patients with CKD is unrealistic and inappropriate. Management strategies aimed at improving adverse outcomes need to take account of this and be developed and implemented through collaboration between primary care and secondary care.