Rationale & Objective

Current guidelines for nephrology referral are based on laboratory criteria. We sought to evaluate whether nephrology referral patterns reflect current clinical practice guidelines and to estimate the change in referral volume if they were based on the estimated risk of kidney failure.

Study Design

Observational cohort.

Setting & Participants

Retrospective study of 399,644 veterans with chronic kidney disease (October 1, 2015 through September 30, 2016).

Exposure

Laboratory referral criteria based on Veterans Affairs/Department of Defense guidelines, categories of predicted risk for kidney failure using the Kidney Failure Risk Equation, and the combination of laboratory referral criteria and predicted risk.

Outcome

Number of patients identified for referral.

Analytical Approach

We evaluated the number of patients who were referred and their predicted 2-year risk for kidney failure. For each exposure, we estimated the number of patients who would be identified for referral.

Results

There were 66,276 patients who met laboratory indications for referral. Among these patients, 11,752 (17.7%) were referred to nephrology in the following year. The median 2-year predicted risk of kidney failure was 1.5% (interquartile range, 0.3%-4.7%) among all patients meeting the laboratory referral criteria. If referrals were restricted to patients with a predicted risk of ≥1% in addition to laboratory indications, the potential referral volume would be reduced from 66,276 to 38,229 patients. If referrals were based on predicted risk alone, a 2-year risk threshold of 1% or higher would identify a similar number of patients (72,948) as laboratory-based criteria with median predicted risk of 2.3% (interquartile range, 1.4%-4.6%).

Limitations

Missing proteinuria measurements.

Conclusions

The current laboratory-based guidelines for nephrology referral identify patients who are, on average, at low risk for progression, most of whom are not referred. As an alternative, referral based on a 2-year kidney failure risk exceeding 1% would identify a similar number of patients but with a higher median risk of kidney failure.

中文翻译：

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基于实验室值、肾衰竭风险或两者的肾脏转诊：一项使用退伍军人事务卫生系统数据的研究

理由和目标

目前的肾脏病学转诊指南是基于实验室标准。我们试图评估肾脏病学转诊模式是否反映了当前的临床实践指南，并评估转诊量的变化（如果它们基于估计的肾衰竭风险）。

学习规划

观察队列。

设置和参与者

对 399,644 名患有慢性肾病的退伍军人的回顾性研究（2015 年 10 月 1 日至 2016 年 9 月 30 日）。

接触

基于退伍军人事务部/国防部指南的实验室转诊标准、使用肾衰竭风险方程的肾衰竭预测风险类别，以及实验室转诊标准和预测风险的组合。

结果

确定转诊的患者人数。

分析方法

我们评估了转诊患者的数量以及他们预测的 2 年肾衰竭风险。对于每次暴露，我们都估计了将被确定为转诊的患者数量。

结果

有 66,276 名患者符合转诊的实验室指征。在这些患者中，有 11,752 名 (17.7%) 在次年被转诊至肾脏科。在所有符合实验室转诊标准的患者中，肾衰竭的 2 年预测风险中位数为 1.5%（四分位间距，0.3%-4.7%）。如果除实验室指征外，转诊仅限于预测风险≥1% 的患者，则潜在转诊量将从 66,276 名患者减少至 38,229 名患者。如果转诊仅基于预测风险，则 1% 或更高的 2 年风险阈值将确定与基于实验室的标准相似数量的患者 (72,948)，中位预测风险为 2.3%（四分位数范围，1.4%-4.6） %)。

限制

缺少蛋白尿测量值。

结论

目前基于实验室的肾脏病学转诊指南确定了平均而言进展风险较低的患者，其中大多数患者未被转诊。作为替代方案，基于 2 年肾衰竭风险超过 1% 的转诊将确定数量相似但肾衰竭中位风险较高的患者。