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Dear Colleague;

Caring for patients with chronic kidney disease (CKD) is a great challenge for both primary care providers and for nephrologists.This challenge is increased when patients are referred to the renal service requiring urgent dialysis.Delayed referral results in emergency dialysis with higher morbidity, mortality and excessive utilization of healthcare dollars.Emergency dialysis jeopardized the dialysis modality choice, endangers the ability to maintain prolonged vascular access, precludes psychological preparation of patients and family and frequently necessitates hospitalization for a catastrophic complex illness.Mortality associated with acute dialysis can be as high as twenty five percent.

Striving to provide optimal and cost-effective care to our mutual patients, we urge the early referral of patients to our service.Referral of patients with progressive renal insufficiency to the renal team should ideally occur before the creatinine clearance has fallen below 40 ml per minute.Please remember that in the small-framed and the elderly a serum creatinine as low as 1.8mg% may indicate severe renal insufficiency.We recommend the early referral of all diabetic patients with creatinines greater than 2.0mg% and of elderly men and women with creatinines greater than 2.0mg% and 1.8mg%, respectively.

Additional reasons for early referral include:

· A diligent search may reveal a potentially reversible cause of renal failure.

· A number of measures may be implemented to preserve the remaining renal function, e.g. good control of blood pressure, glucose control in diabetics, nutritional guidance, and avoidance of nephrotoxic drugs.

· Upper extremity vessels may be preserved for placement of a native arteriovenous fistula, which is the most reliable type of vascular access.Since it may take up to six months for a fistula to mature, it is critical that early surgical referral be made.Dialysis grafts and catheters are sub-optimal because of recurrent thrombosis and infection.In addition, central venous catheters may irreversibly damage proximal veins precluding future use of that extremity for vascular access.The cost of these complications in the U.S. amounts to over one hundred million dollars annually.

· Treatment of anemia with erythropoietin may significantly improve life quality.

· Secondary hyperthyroidism may be prevented with phosphate binders and calcitriol.

· Referral to a team consisting of a nephrologist, renal dietitian, dialysis nurse, social worker and financial counselor allows time to establish the best treatment modality for the patient, develop financial support if needed and to allay the fears of both patient and family.

Following initial consultation, a long-term management plan will be designed to assist you in caring for the patient until they develop end stage renal failure.We wish to thank you for your help in providing better care for our mutual patients.Please feel free to contact us with any questions or suggestions.

Dr.___________Dr. _____________ Dr. _____________