Chronic kidney disease is associated with increased morbidity, mortality, haematological and biochemical abnormalities. Increasing age is associated with an increased prevalence of CKD [3
]. There is evidence however that there may be a pattern of restricted referral to Nephrologists from medical practitioners caring for the elderly [10
]. Our study demonstrated that CKD is common in patients over 65 attending a tertiary geriatrics outpatient clinic. CKD was associated with anaemia and mortality but despite this few patients were referred to a nephrologist.
Mortality has been demonstrated to be inversely associated with kidney function, with the risk increased once the eGFR is below 60
]. Interventions that can slow progressive renal failure exist but sometimes require input from a nephrologist [13
]. In addition a nephrologist can assist with the optimal management of mineral bone disease that also occurs with increasing prevalence once eGFR
Anaemia can be directly related to CKD, with its increased risk commencing once the eGFR reaches 60
or less [7
]. This was demonstrated in our study with an 11.3% prevalence of anaemia in our population. Quality of life can be improved considerably, and blood transfusions avoided, with the prescription of erythropoiesis stimulating agents [18
]. In Australia, government subsidised prescription of these agents is restricted to Nephrologists and Haematologists.
The prevalence of CKD with a eGFR
in our geriatric outpatient population was 44%, with an increased rate with increasing age. This is consistently greater than the prevalence of CKD in other cohorts - 14.7% of over 65
year old residents of long-term care facilities, 15.6% in outpatient clinics, 17.5% in a community-based laboratory, and 22.4% over 65
year olds in a primary care setting [5
]. Other studies have shown that a considerable proportion of patients do not receive evidence based intervention for CKD in non-nephrology practices [23
]. Suggesting that referral of this population to a Nephrologist may assist in the diagnosis of the aetiology of the CKD and to ensure that optimal management was being prescribed.
Contrary to the belief of some medical practitioners, commencement of dialysis in the elderly may be associated with an improved quantity and quality of life [24
]. As a consequence of multiple factors, the greatest increase in new dialysis patients in Australia and the UK are in the over 65 age group [1
]. Late referral to a nephrologist may delay optimal preparation for dialysis and is associated with worse outcomes, prompting national and international Guidelines for early referral of CKD patients to Nephrologists [24
Despite this there was a surprisingly low referral rate of patients with CKD to a Nephrologist, 50% of the recommended numbers based upon Kidney Health Australia guidelines of eGFR
g/L with eGFR
]. It is unclear why this practice pattern exists [28
]. It may be related to a previous bias towards not dialysing the elderly or the belief that dialysis is not appropriate or in the best interests of the elderly.
The Nephrology workforce in SCGH and in the State is similar to the rest of Australia, with 72.7 end-stage kidney disease (ESKD) patients per full-time equivalent nephrologist in WA compared with 60.3 for Australia [30
]. In addition the demographics of ESKD patients in WA is similar to the rest of Australia with 453 Dialysis patients per million population, compared with 471 in Australia [31
]. The peak in the age group for prevalent dialysis patients in WA and Australia is also the same at 65 to 74
years old [31
]. This suggests that results from this paper may be generalizable to the rest of Australia.
Limitations include its retrospective nature. While a complete list of people attending the geriatrics outpatients clinic during the baseline period was obtained, data was only obtained on those patients that were having blood tests performed for clinical reasons. This bias is likely to overestimate the true prevalence rates. Additionally, an examination was not made to see if the CKD patients identified were already on optimal treatment to slow progressive kidney failure. Regardless, those with anaemia and advanced CKD would probably benefit from referral to a nephrologist. Other metabolic complications of CKD were not examined due to the lack of information as measurement of these parameters (e.g. serum phosphate) were not part of usual clinical practice in these clinics.