Nephrol Dial Transplant (2002) 17: 9-10
© 2002 European Renal Association-European Dialysis and Transplant Association
SECTION I: Measurement of renal function, when to refer and when to start dialysis
I.2 When to refer to a nephrology clinic
AbstractGuideline I.2.1
A. Referral to nephrology should be considered when the GFR is <60 ml/min and is mandatory when the GFR is <30 ml/min.
B. If a GFR prediction or measurement is not available, patients with chronic renal failure should be referred to a nephrologist when on two consecutive measurements, plasma creatinine exceeds 150 mmol/l in men and 120 mmol/l in women, corresponding to a GFR of 
50 ml/min. These patients should be referred whether or not there are other indications of chronic renal disease, such as proteinuria.
Guideline I.2.2
A. Patients with a GFR <60 ml/min should have a treatment strategy aimed at:
- Reducing the mortality and morbidity of renal failure. In general, this is similar to the strategy in dialysis patients with respect to management of renal anaemia, nutrition, acid-base, calcium, phosphate homeostasis, and blood pressure control.
(Evidence level: B)
- Delaying or preventing the progression of renal failure. This will include specific treatment of the underlying renal condition, regular GFR and protein excretion measurements to guide therapy, strict blood pressure control, ACE inhibition in patients with diabetes mellitus and those with protein excretion >3 g/day, strict blood glucose control in diabetes, and modification of risk factors (including smoking, lipid abnormalities, excessive protein intake).
(Evidence level: B)
- Referral to a nephrologist should be considered in order to implement this therapy.
- At a GFR of 60 ml/min the serum creatinine is 140 µmol/l for men and 105 µmol/l for women.
Guideline I.2.3
A. Patients whose GFR is <30 ml/min and declining despite therapy should be under the care of a nephrologist and be prepared for the onset of end-stage renal failure. This preparation includes:
- Choosing the most appropriate location (e.g. home or hospital) and form of treatment (e.g. HD, CAPD, pre-emptive transplantation or conservative treatment). This choice will involve discussion between patients, their families and nephrology staff. This process may need support from specialist renal counsellors and social workers.
(Evidence level: C)
- Preparing appropriate dialysis access in a timely manner.
(Evidence level: B)
- Hepatitis vaccinations should be considered. The effects must be assessed regularly.
- When GFR has fallen to 15 ml/min/1.73 m2 the assessments should be intensified to about once monthly with special attention to control of hypertension, fluid overload, biochemical abnormalities, and management of malnutrition.
At a GFR of 30 ml/min the serum creatinine is180 µmol/l for men and 150 µmol/l for women.