Keywords
chronic kidney disease - diabetic kidney disease - diabetic nephropathy - end-stage renal disease - type 1 diabetes - type 2 diabetes
Introduction
Kidney disease is common in diabetes.[1] In spite of great advances in diagnosis and management of diabetic kidney disease (DKD), renal outcomes still remain suboptimal. One of the main reasons for this is delayed referral to nephrology specialist clinics. Such delay may occur due to multiple causes, including nonavailability of qualified professionals. Often, however, this is because of lack of awareness.
Barriers to Referral
Many diabetes care providers may not be aware that all kidney disease in persons with diabetes is not DKD. Some authors use DKD as a broad term, which has two varieties: diabetic nephropathy (DN) and non-DKD. Other authors use DKD interchangeably with DN.[2]
[3] It may also be difficult to gauge the severity, achieve therapeutic targets, or manage multiple comorbid conditions that need attention in kidney disease.
Need for Referral
Data show that multidisciplinary endocrinology and nephrology care in the DKD clinic is associated with a lower risk of end–stage renal disease (ESRD) and improves outcomes.[4] Timely care of the kidney also helps in prevention of progression of chronic kidney disease.[5] A nephrology referral, therefore, helps in tertiary prevention of diabetes and secondary prevention of diabetes complications. Appropriate nephrology intervention in DKD reduces the risk of cardiovascular complications as well.
Indications for Referral
However, all persons with diabetes cannot be referred to nephrology care. The number of qualified nephrologists is inadequate to take care of all persons with DKD, let alone diabetes.
The Indian Council of Medical Research (ICMR) 2018 guidelines on type 2 diabetes mellitus state that “if there are high risk factors in the patient and/or there is any abnormality in history, examination and preliminary investigations, these patients need to be referred to specialists for further management.”[6]
The ICMR calls for referral of DN patients to a nephrologist if these is severe/resistant hypertension, serum potassium greater than 5.5 mEq/L, nephritic range proteinuria, proteinuria in the absence of retinopathy, serum creatinine greater than 1.5 mg %, pregestational diabetes or gestational diabetes mellitus with proteinuria, estimated glomerular filtration rate (eGFR) less than 60 mL/min (as calculated by Modification of Diet in Renal Disease [MDRD]), or fluid overload/oliguria. While these eight points are a comprehensive coverage of the various complications of DN, they are presented in a manner that may complicate the subject for the unexperienced physician.
The Research Society for Study of Diabetes in India (2017) guidelines for management of type 2 diabetes[7] lay down four indications for referral of DN to a nephrologist: eGFR less than 30 mL/min/1.73 m[2], progressive deterioration of kidney function, persistent proteinuria, biochemical or fluid retention, or difficulty in diagnosis (to rule out nondiabetic renal disease). These indications, though easy to follow, may not help all deserving patients access nephrology services in a timely manner.
Suggested Best Practice
Hence, a simple yet comprehensive algorithm is required to triage persons who need specialist referral. A list of such indications is mentioned in [Table 1]. It must be noted that referral may vary depending on the ability and interest of the primary care physician/diabetologist/endocrinologist in treating DKD. A physician who is interested and well trained in nephrology may not feel the need to refer stable DKD patients. Conversely, referral may be increased as such a physician will be able to suspect non-DKD, such as glomerulonephritis or renal vasculitis, more frequently. A basic checklist for all physicians is mentioned in [Table 2].
Table 1
Indications for nephrology referral in diabetes
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Abbreviations: AKI, acute kidney injury; BP, blood pressure; eGFR, estimated glomerular filtration rate; RBC, red blood cells; UACR, urinary albumin creatinine ratio; UTI, urinary tract infection.
aAll values must be confirmed by repeat testing.
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Dilemma in diagnosis
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Severity of renal diseasea
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Dilemma in therapya
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Sudden worsening of azotemic symptoms
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Table 2
Physician's responsibility in nephrology care for persons with diabetes
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Abbreviations: CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate; UACR, urinary albumin creatinine ratio.
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All persons with diabetes
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Bone disease: Serum calcium, phosphorus, alkaline phosphatase, parathormone, vitamin D
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Education: Sick day rules, diet, avoidance of nephrotoxic drugs, judicious use of radiocontrast,
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The Nephrologist’s Role
Most people with DKD reach the nephrology after ESRD has occurred, and complications have set on. Timely referred allows the nephrologist to institute preventive and therapeutic measures, designed to retard the progression of renal impairment, minimize complications, and enhance quality of life. Regular monitoring may cause acute kidney injury and worsen renal function. Therapeutic counseling, performed in an empathic and knowledgeable manner, allows the patient and her family to prepare for life ESRD, using dialysis and renal transplant as treatment options.
Summary
While these suggestions are not absolute, they do provide a framework upon which to build a pragmatic referral policy. Such a policy will be of relevance to the majority of health care systems operating in South Asia and beyond.
