Change Concept 2

Timely referral to nephrologist

  • Primary care physicians utilize ESRD/CKD referral criteria to ensure timely referral of patients to nephrologists.
  • Establish meaningful criteria for PCPs who may not perform GFR or creatinine clearance testing.
  • Nephrologist documents AVF plan for all patients expected to require renal replacement therapy.
  • Designated nephrology staff person educates patient and family to protect vessels, when possible using bracelet as reminder.

Reach out to the primary care physician (PCP) community to educate clinicians on appropriate referral criteria.

Changes for Improvement:

Educate Primary Care Physicians to Utilize Pre-End Stage Renal Disease/Chronic Kidney Disease Referral Criteria

The new Kidney Disease Outcomes Quality Initiative (K/DOQI) Chronic Kidney Disease (CKD) Guidelines provide a clear standard for classification and management of patients with kidney disease.  Primary care physicians (PCPs) should use these guidelines to evaluate, manage, and refer their patients with evidence of kidney disease. Referral to a nephrologist should be made for all patients with evidence of CKD, but certainly before the glomerular filtration rate (GFR) falls below 30 ml/minute (Stage 4 CKD) for nondiabetics or below 60 ml/minute (Stage 3 CKD) for diabetics.

Ideally, the PCP’s regular laboratory will convert serum creatinine measurements to GFR.  If not, office staff or the PCP can easily use an online GFR calculator to do the conversion.

Document an AVF Plan

Document an AV fistula plan for all patients expected to require renal replacement therapy (RRT), regardless of the type of RRT being considered.

Educate Patients and Families on the Benefits of AVFs and on Protecting Vessels

Prepare the patient and the family for an AV fistula before they see a surgeon.  Designate a nephrology staff person to educate patients and families on the benefits of AV fistulae and protecting vessels.

Veins should be protected as soon as there is any evidence of possible kidney disease, since ruining them compromises the opportunity and choices for a native AV fistula.

At the first sign of kidney disease, the physician should tell the patient and his or her family that hemodialysis may be required. The physician should examine the patient’s arms and advise the patient to protect his or her veins.  The patient should also be encouraged to request that the dorsum of the hand be used for blood draws or IVs and to avoid using the forearm veins (unless in an emergency situation) in order to preserve them for future access.  Patients should consider wearing a medical alert bracelet as a reminder to ensure vessel protection.  When the patient is in the  hospital, a sign should be placed a the bedside to remind staff about vessel preservation.

Related Tools

CKD Quick Reference Guide for the Primary Care Provider

A one page quick reference guide, derived from the National Kidney Foundation K-DOQI Clinical Guidelines, which addresses key markers for identification of chronic kidney disease and seven action steps (when to refer to nephrologist, discontinuation of unsafe medications, ACE & ARB treatment, ASA treatment, lab tests, saving the arm and patient education). Revised 8/10

Patient Educational Flyer 

A one page flyer that provides advantages and disadvantages of the three hemodialysis access types for patient and family education. Available in Spanish.

AV Access Plan Checklist for Nephrologists 

A checklist for documenting key information for a surgical plan to place AV fistulae, including mandatory preoperative vein mapping for all patients. Revised 9/09

Sample Letter to PCPs/Insurance Companies

A sample letter for use by nephrologists to educate primary care physicians (PCP) on the importance of early referral of patients for the treatment of chronic kidney disease with rationale, appropriate trigger for referral and assurance that PCP’s patient will return to PCP’s care.  Revised 9/09

Recommendations for the Minimal Use of PICC Lines

FFBI white paper recommending that PICC lines not be placed in anyone identified as having mid-Stage 3 chronic kidney disease (CKD), Stage 4 and 5 CKD or ESRD with instructions to obtain GFR estimates for all patients with high serum creatinine levels, and to defer a PICC line decision until it is clear that the patient does not have CKD.

Recommendations for the Avoidance of Radial Artery Access for Procedures

This document discusses avoidance of the radial artery as an access vessel for cannulation in patients with CKD stage 4, 5 or ESRD due to possible loss of upper extremity vasculature.

Vein Preservation and Hemodialysis Fistula Protection

A one page paper with instructions for health care providers on vein preservation and hemodialysis fistula protection including directions for protection of forearm veins, for patients with working hemodialysis access and for patients with CKD or at risk for CKD.

Fistula First – Overcoming Barriers

A summary of barriers to fistula placement with discussion and comment addressing nephrology control of vascular access, pay for performance in dialysis, patient choice and provider accountability, primary care physician concerns regarding co-morbidities and patient age, availability of skilled surgeons and poor cannulation skills by dialysis facility staff.

Pre-ESRD Fistula Care – Saving Vasculature

A paper addressing planning ahead for vascular access with recommendations for nephrologists to help patients have the best chance for ending up with a functioning AVF.

What Nephrologists Need to Know about AVF Creation

A tip sheet for nephrologist use during collegial discussions with information and references related to the creation of an AVF with the vascular access surgeon.