Change Concept 2: Timely Referral to Nephrologist

Reach out to the primary care physician (PCP) community to educate clinicians on appropriate referral criteria.

• Primary care physicians utilize ESRD/CKD referral criteria to ensure timely referral of patients to nephrologists.
• Establish meaningful criteria for PCPs who may not perform GFR or creatinine clearance testing.
• Nephrologist documents AVF plan for all patients expected to require renal replacement therapy.
• Designated nephrology staff person educates patient and family to protect vessels, when possible using bracelet as reminder.

Changes for Improvement

Educate Primary Care Physicians to Utilize Pre-End Stage Renal Disease/Chronic Kidney Disease Referral Criteria

The new Kidney Disease Outcomes Quality Initiative (K/DOQI) Chronic Kidney Disease (CKD) Guidelines provide a clear standard for classification and management of patients with kidney disease.  Primary care physicians (PCPs) should use these guidelines to evaluate, manage, and refer their patients with evidence of kidney disease. Referral to a nephrologist should be made for all patients with evidence of CKD, but certainly before the glomerular filtration rate (GFR) falls below 30 ml/minute (Stage 4 CKD) for nondiabetics or below 60 ml/minute (Stage 3 CKD) for diabetics.

Ideally, the PCP’s regular laboratory will convert serum creatinine measurements to GFR.  If not, office staff or the PCP can easily use an online GFR calculator to do the conversion.

Document an AVF Plan

Document an AV fistula plan for all patients expected to require renal replacement therapy (RRT), regardless of the type of RRT being considered.

Educate Patients and Families on the Benefits of AVFs and on Protecting Vessels

Prepare the patient and the family for an AV fistula before they see a surgeon. Designate a nephrology staff person to educate patients and families on the benefits of AV fistulae and protecting vessels.

Veins should be protected as soon as there is any evidence of possible kidney disease, since ruining them compromises the opportunity and choices for a native AV fistula.

At the first sign of kidney disease, the physician should tell the patient and his or her family that hemodialysis may be required. The physician should examine the patient’s arms and advise the patient to protect his or her veins. The patient should also be encouraged to request that the dorsum of the hand be used for blood draws or IVs and to avoid using the forearm veins (unless in an emergency situation) in order to preserve them for future access. Patients should consider wearing a medical alert bracelet as a reminder to ensure vessel protection. When the patient is in the hospital, a sign should be placed at the bedside to remind staff about vessel preservation.

Resources

Vein Preservation and Hemodialysis Fistula Protection

A one page paper with instructions for health care providers on vein preservation and hemodialysis fistula protection including directions for protection of forearm veins, for patients with working hemodialysis access and for patients with chronic kidney disease (CKD) or at-risk for CKD.

Recommendations for the Avoidance of Radial Artery Access for Procedures

This document discusses avoidance of the radial artery as an access vessel for cannulation in patients with CKD stage 4, 5 or ESRD due to possible loss of upper extremity vasculature.

Recommendations for the Minimal Use of PICC Lines

Fistula First Breakthrough Initiative white paper recommending that Peripherally Inserted Central Catheter (PICC) lines not be placed in anyone identified as having mid-Stage 3 CKD, Stage 4 and 5 CKD or ESRD with instructions to obtain Glomerular Filtration Rate (GFR) estimates for all patients with high serum creatinine levels, and to defer a PICC line decision until it is clear that the patient does not have CKD.