There has been an increase in the awareness of chronic kidney disease (CKD) in the United States over the past decade (1).  CKD as a complication of diabetes and hypertension (HTN) has also become more of a focus for primary care providers (PCP), especially regarding patients with diabetes (2).  We also now have better estimates of the number of people with CKD.  There are almost 20 million people with stage 2 or 3 CKD and more than 1 million with stage 4 and 5 (1).  Given this level of prevalence, and the knowledge of the pathology and treatment of CKD, it is a condition that lends itself to guideline-assisted care.  For instance, it is widely recommended that patients with the two most common risk factors for CKD, diabetes and HTN, should be screened annually for CKD with a urine microalbumin/creatinine test (3).  It is also recommended that patients with DM and proteinuria be prescribed angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) unless there is a specific contraindication to these medications (3).  Also included in the many published guideline-type recommendations for care of patients with CKD are opinions regarding when such a patient should be referred to a nephrologist (4-6).  This is important to ensure both that patients are not under- or over-referred to nephrologists.  Under-referring may deny a patient the added expertise needed to delay progression to end stage renal disease (ESRD) or not prepare the patient sufficiently for renal replacement therapy (dialysis or transplant) when it is needed.  Over-referring would unnecessarily burden nephrologists with patients whose CKD could still be adequately managed by their PCP.  After all, there are more 2000 patients with CKD stage 2-5 in the U.S. for every practicing nephrologist (7). 
 
When should, then, a CKD patient be referred to a nephrologist? To view full article, click here.