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Chronic Kidney Disease (CKD) Referral Guidelines

Suggested Criteria/Guidelines for PCP Referral to Nephrology:


CKD management is a great challenge for both primary care physicians and for nephrologists. This challenge increases when patients are referred late to a nephrologist. Delayed referral leads to more rapid progression to ESRD and in some cases acute dialysis with higher morbidity, mortality and excessive cost.


Target population

Adults >18 years of age with chronic kidney disease

Clinical Goal

Slow down the progression of CKD to ESRD and lower the risk of adverse ASCVD outcomes

Criteria for referral to a Nephrologist

  • GFR < 45ml/min (Stage 3b CKD) with or without abnormal urinary findings
  • GFR < 60ml/min (Stage 3a CKD) with albuminuria, proteinuria, pyuria or microscopic hematuria 
  • GFR <60 ml/min with diabetes or uncontrolled hypertension (patient requiring >3 drugs for BP control)- CKD with CHF and fluid management issues
  • Unexplained proteinuria, microscopic hematuria irrespective of GFR
  • CKD with rapid decline in GFR
  • Electrolyte abnormalities
  • Severe metabolic acidosis
  • Patient with kidney transplant
  • CKD with mineral bone disease – elevated PTH and Phosphorus
  • Abnormal renal ultrasound or CT scan

Relative criteria for referral to a Nephrologist

  • GFR < 60ml- Stage 3a- CKD patients enrolled in CKD comprehensive care program have a significant delay in the onset of ESRD, longer life expectancy once on dialysis and are more likely to receive a renal transplant.
  • New AKI – declining GFR > 25% from baseline

Follow up of CKD patients

  • Stage 3a (GFR <60 ml/min)- Every 4 months
  • Stage 3b (GFR <45 ml/min)- Every 3 months
  • Stage 4 (GFR <30 ml/min)- Every 2 months
  • Stage 5 (GFR <15 ml/min)- Every month



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