Elderly patients with chronic kidney disease: do they really need referral to the nephrology clinic?

Introduction: Chronic kidney disease (CKD) is becoming increasingly common, especially in the elderly. In the UK, there has been a marked increase in the awareness and detection of CKD over the last decade. This is largely attributable to the introduction of automated estimated glomerular filtration rate (eGFR) reporting and renal indicators in the primary care Quality and Outcomes Framework (QOF) initiative, both of which were introduced in 2006. These two initiatives have had a significant impact on referral patterns to renal services. Across the UK there has been a sustained increase in patients referred to nephrology clinics. The increased referrals have led to an older patient cohort, for whom specialist nephrology input is of questionable clinical benefit. This study aims to assess the outcomes of such patients referred to nephrology clinics in Dorset.

Methods: Retrospective data were collected on all new referrals to the nephrology outpatient clinic at Dorset County Hospital between April 2006 and March 2007. We specifically examined all patients >80 years of age who had CKD Stage 4 or 5. Outcomes of interest included the rate of decline in eGFR, renal-specific management implemented by the clinic, need for renal replacement therapy and death. These outcomes were used to compare the difference between those patients kept under regular follow-up in the nephrology clinic and those discharged back to primary care. Patients were followed up until March 2014.

Results: In all, 124 patients who were ≥80 years of age had CKD Stage 4 (115 patients) or 5 (9 patients). The mean age was 84.4 (range 80-95) years. In all, 66 patients were kept under regular follow-up in the clinic and 58 patients were discharged back to primary care. Patients kept under follow-up tended to have a lower median eGFR at referral (22 mL/min/1.73 m² versus 26 mL/min/1.73 m²; P = 0.051) and had a significantly more rapid decline in mean eGFR over the next 7 years (1.58 mL/min/1.73 m²/yr versus 0.357 ml/min/1.73 m²/yr; P = 0.023) compared with those discharged back to primary care. More patients were commenced on erythropoietin (12 versus 3; P = 0.03) and more patients were commenced on dialysis (5 versus 0; P = 0.03) in the follow-up group compared with those discharged back to primary care. No patients from either group underwent a kidney biopsy. In those patients followed up, 55 (83%) died, with a median time to death of 2.66 years [interquartile range (IQR) 1.14-4.97]. Of the patients discharged, 45 (78%) died, with a median time to death of 3.57 years (IQR 2.31-5.68).

Conclusions: This study highlights the uncertain clinical benefit gained from referral to the nephrology clinic for the majority of elderly patients and suggests that for many cases their care could be safely and appropriately managed in the primary care setting. With the increasing prevalence of CKD in the elderly and increasing pressure on new patient clinic slots, referral of a select group in which a specific intervention is being considered may be more appropriate.