Elevated levels of serum creatinine: recommendations for management and referral

Background: The potential benefits of earlier referral to a nephrologist of patients with elevated levels of serum creatinine include identifying and treating reversible causes of renal failure, slowing the rate of decline as sociated with progressive renal insufficiency, managing the coexisting cond itions associated with chronic renal failure and facilitating efficient ent ry into dialysis programs for all patients who might benefit. Methods: A subcommittee of the Canadian Society of Nephrology, which includ ed representatives from family practice and internal medicine, conducted a MEDLINE search for the period 1966 to 1998 using the key words referral and consultation, dialysis, hemodialysis, peritoneal dialysis, renal replaceme nt therapy and kidney diseases. Where published evidence was lacking, concl usions were reached by consensus. Guidelines: Earlier referral to nephrologists of patients with elevated cre atinine levels is expected to lead to better health care outcomes and lower costs for both the patients and the health care system. All patients with newly discovered renal insufficiency (as evidenced by serum creatinine elev ated to a level above the upper limit of the normal range of that laborator y, adjusted for age and height in children) must undergo investigations to determine the potential reversibility of disease, to evaluate the prognosis and to optimize planning of care. All patients with an established, progre ssive increase in serum creatinine level should be followed with a nephrolo gist. Adequate preparation for dialysis or transplantation (or both) requir es at least 12 months of relatively frequent contact with a renal care team . Nephrologists should provide consultation in a timely manner for any pati ent with an elevated serum creatinine level. In addition, they should provi de advice about what aspects of the condition require particularly urgent o r emergency assessment. Sponsors: This clinical practice guideline has been endorsed by the Canadia n Society of Nephrology and the College of Family Physicians of Canada. Mee ting, teleconference and travel expenses of the Referral Guideline Subcommi ttee were covered by The Momentum Program, a collaboration between Baxter C orp. and lanssen-Ortho Inc. However, the authors are solely responsible for the editorial content of this article.