1.8.6.0 Referral to a Nephrologist
Consider referral to a physician experienced in the care of kidney disease when there is uncertainty about the etiology of kidney disease, difficult management issues (anemia, secondary hyperparathyroidism, metabolic bone disease, resistant hypertension, or electrolyte disturbances), or advanced kidney disease (eGFR <30 mL/min/1.73 m2) requiring discussion of renal replacement therapy for ESRD. The threshold for referral may vary depending on the frequency with which a provider encounters patients with diabetes and kidney disease. Consultation with a nephrologist when stage CKD develops (eGFR <30 mL/min/1.73 m2) has been found to reduce cost, improve quality of care, and delay dialysis (76). However, other specialists and providers should also educate their patients about the progressive nature of CKD, the kidney preservation bene- fits of proactive treatment of blood pressure and blood glucose, and the potential need for renal replacement therapy.