Optimal referral is early referral.

The number of patients receiving renal replacement therapy in the United Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public health problem with significant comorbidity and mortality. Several organizational guidelines have been developed in an attempt to identify when appropriate referral to nephrology services should occur; however, many of these guidelines provide conflicting recommendations on referral. Recent surveys suggest that more than 30% of patients with CKD are referred later than is ideal. Late referral of patients with CKD is associated with increased patient morbidity and mortality, increased need for and duration of hospital admission, and increased initial costs of care following commencement of dialysis. Additional benefits of early referral include identifying and treating reversible causes of renal impairment and managing the multiple coexisting conditions associated with CKD. Referral time also affects the choice of treatment modality. Patients and their families should receive sufficient information regarding the nature of their CKD and the options for treatment so that they can make informed decisions concerning their care. Literature addressing when to refer to low-clearance or pre-dialysis clinics is limited. Existing data suggest that such clinics and patient education programs may facilitate improved medical care for patients, greater patient involvement in selection of the mode of dialysis, reduction in the need for "urgent start" dialysis, and improved short-term survival and quality of life after initiation of dialysis. Audit of our pre-dialysis clinic has demonstrated improved patient outcomes, and we view the early-referral service as an essential component of the patient pathway.