Agrawal Varun, Ghosh Amit K, Barnes Michael A, McCullough Peter A
Department of Internal Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA.
Clin J Am Soc Nephrol. 2009 Feb;4(2):323-8. doi: 10.2215/CJN.03510708.
Many patients with chronic kidney disease (CKD) are seen by primary care physicians who may not be aware of indications or benefits of timely nephrologist referral. Late referral to a nephrologist may lead to suboptimal pre-end stage renal disease care and greater mortality. It is not known whether current postgraduate training adequately prepares a future internist in this aspect of CKD management.
DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: The authors performed an online questionnaire survey of internal medicine residents in the United States to determine their perceptions of indications for nephrology referral in CKD management.
Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution of 166 PGY 1,187 PGY 2 and 126 PGY 3. Few residents chose nephrology referral for proteinuria (45%), uncontrolled hypertension (64%), or hyperkalemia (26%). Twenty-eight percent of the residents considered consulting a nephrologist for anemia of CKD, whereas 45% would do so for bone disorder of CKD. Most of the residents would involve a nephrologist at glomerular filtration rate (GFR) <30 ml/min/1.73 m(2) (90%) and for rapid decline in GFR (79%). Many residents would refer a patient for dialysis setup at GFR 15 to 30 ml/min/1.73 m(2) (59%); however, 18% would do so at GFR <15 ml/min/1.73 m(2). Presence of CKD clinic experience or an in-house nephrology fellowship program did not considerably change these perceptions.
Results show that internal medicine residents have widely differing perceptions of indications for nephrology referral. Educational efforts during residency training to raise awareness and benefits of early referral may improve CKD management by facilitating better collaboration between internist and nephrologist.
许多慢性肾脏病（CKD）患者由初级保健医生诊治，这些医生可能并不了解及时转诊至肾病科的指征或益处。延迟转诊至肾病科可能导致终末期肾病前期治疗效果欠佳，死亡率更高。目前尚不清楚当前的研究生培训是否能让未来的内科医生在CKD管理的这方面做好充分准备。
设计、地点、参与者与测量方法：作者对美国内科住院医师进行了一项在线问卷调查，以确定他们对CKD管理中肾病转诊指征的看法。
479名住院医师完成了调查，研究生年级（PGY）分布为：166名PGY1、187名PGY2和126名PGY3。很少有住院医师因蛋白尿（45%）、未控制的高血压（64%）或高钾血症（26%）而选择转诊至肾病科。28%的住院医师会考虑为CKD贫血咨询肾病科医生，而45%会为CKD骨病咨询肾病科医生。大多数住院医师会在肾小球滤过率（GFR）<30 ml/min/1.73 m²（90%）以及GFR快速下降（79%）时让肾病科医生参与。许多住院医师会在GFR为15至30 ml/min/1.73 m²（59%）时将患者转诊进行透析准备；然而，18%会在GFR<15 ml/min/1.73 m²时这样做。有CKD门诊经验或内部肾病专科培训项目并没有显著改变这些看法。
结果表明，内科住院医师对肾病转诊指征的看法差异很大。住院医师培训期间的教育努力，以提高对早期转诊的认识和益处，可能通过促进内科医生和肾病科医生之间更好的合作来改善CKD管理。
