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Elderly patients with kidney disease ‘still require referral’

Criticism of GP referrals for chronic kidney disease in elderly patients is unjustified as this group is just as likely to require specialist care, concludes a UK analysis.

The study of patients at 25 hospital outpatient clinics in Wales found despite rising rates of elderly patients referred to secondary care since the introduction of eGFR, there was no difference in intervention rates between those aged under 75 years and those over 75.

The researchers said they showed that the ongoing debate over the referral of elderly patients with stage three CKD was unfounded, and that referral should be based on the severity of disease, not age.

The researchers from University Hospital Wales in Cardiff retrospectively followed nearly 550 patients presenting at outpatient clinics over 19 weeks within a single NHS trust that covered 20% of the Welsh population.

Clinical parameters, including eGFR, were recorded at the time of the clinic appointment, with eGFR recordings from the previous six and 12 months also taken to measure stability over a one year period.

There were large numbers of elderly patients presenting at the clinics, with 43% of those seen in outpatient clinics aged over 75 years.

But the researchers found no significant difference between the over 75s and under 75s in terms of intervention rates, defined as a change to medication or further referral, with figures of 31% and 33% of patients respectively. Medication changes included any alteration, initiation or discontinuation of drugs, while referrals covered those to a renal anaemia team, surgical team and dialysis units.

There was also no significant difference in eGFR stability between the over 75s and under 75s over a 12 month period, with 24% of under 75s and 18% of over 75s presenting an unstable eGFR.

But the older cohort did have a greater degree of renal anaemia requiring erythropoietin than the younger group.

The authors concluded that the results showed that elderly CKD patients in nephrology outpatient clinic were managed no differently to a younger cohort, apart from higher rates of renal anaemia.

They concluded: ‘Despite an increase in the mean age of nephrology outpatients in the era of automated eGFR reporting, we can provide no evidence that the over 75 year old age group have a lesser need for specialist nephrology intervention than the under 75 group.’

Professor Mike Kirby, a GP in Radlett, Hertfordshire, and editor of the Primary Care Cardiovascular Journal, said this supported GPs referring and managing elderly patients the same as younger patients with CKD.

He said: ‘I’m against ageism for CKD, and I don’t support the idea of using age, in this case 75 years, as a cut-off.  Treatment decisions should be taken on a case-by-case basis.’

He added that it was important that managing elderly patients well could prevent further complications from CKD.

He said: ‘If we manage patients well in stage three, with good blood pressure control and proteinuria management, then it reduces the likelihood of them reaching stage 4, which is where renal anaemia occurs and the associated issues that reduce quality of life such as higher risk of falls and cognitive problems.’


                                                                Over 75s                          Under 75s

Intervention rates                                        30.7%                               32.5%

Unstable eGFR over 12 months       17.9%                               24.3%8


European Journal of Internal Medicine 2012, available online 28 September