Case 16: The Late Referral

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Session S2 · 2026-10-27 · optional-30 · 30 min Anchor: Chronic kidney disease — preparing for kidney replacement therapy · Integrates: progression risk and referral timing (KFRE in plain terms), vascular access and vein preservation, modalities with transplant referral and conservative care, uremic symptoms and AEIOU, CKD-MBD and acidosis first steps, nutrition counsel Runs 10:00–10:30 only if the full 150-minute block is available. One-line hook: Her first kidney visit comes at an eGFR of 17, and nobody has ever said the word dialysis to her. This case is about what a referral is for, what waiting costs, and how much of it a new PA can still save.

Fictional patients. Every name, date and number in this case is invented for teaching.

Learning Objectives

Answers for this section: W1 · W2 · Q3 · Q4 · Q5 · Q6 · Q7 · Q8

1. Identify the nephrology referral indication in a lab trend — eGFR below 30, substantial persistent albuminuria, significant progression or elevated validated kidney-failure risk — and explain a KFRE result in plain words, using current KDIGO criteria rather than a single copied threshold.
2. Screen for uremic symptoms and the AEIOU emergencies, and explain why dialysis starts for symptoms that medical treatment cannot control rather than at an eGFR number.
3. Lay out kidney-replacement preparation at G4: teaching on every option, transplant referral with living donation raised, and an access plan that starts with protecting veins.
4. Give first-line CKD nutrition advice (protein about 0.8 g/kg, sodium under 2 g, phosphate additives, potassium by the labs), and name the first steps for CKD acidosis and mineral-bone disease (discussed, not tested).
5. Recognize who should be offered conservative kidney management, and describe it as active care.

Warm-Up (individual commit before the case)

Answers for this section: W1 · W2

Part 1 — Presentation

Answers for this section: Q3 · Q4

Mrs. Joan Brecht, 66, a retired school-bus driver from a farm town an hour from Dubuque, comes to the nephrology clinic with her husband on a Tuesday morning. It is the first time she has seen a kidney specialist.

She has had type 2 diabetes for 19 years, high blood pressure for 15, and diabetic eye disease treated with laser. Nine weeks ago an outside hospital admitted her with an infected ulcer under her right big toe; the bone beneath it was infected (osteomyelitis). Part of the toe was removed, and she went home with a PICC — a peripherally inserted central catheter, threaded through a vein in her left upper arm — for six weeks of intravenous antibiotics from a home-infusion company. The course ended three weeks ago and the PICC came out that day. The discharge summary reads: "CKD stage 4. Refer to nephrology as an outpatient."

For two months she has been queasy most mornings, eats about half her usual breakfast, and says food "tastes like tin." She has lost 3 kg since the admission. No vomiting, itching, confusion, chest pain or breathlessness; she passes her usual amount of urine. She is right-handed. Before she sits down she asks, "Is this the start of dialysis?" No one has ever used that word with her, or the word transplant.

Her primary-care record (same laboratory throughout)

Her creatinine at the infusion company's week-6 check, three weeks ago, was 3.1 (bicarbonate 18 that day), so today's value is a steady state and the eGFR can be read.

Vitals: BP 146/82 (seated, second reading) · Pulse 76 · Temp 36.8 °C · Resp 14 · SpO₂ 97% on room air · Weight 75.0 kg (78.0 kg before the admission) · Height 163 cm.

Exam: Alert, fluent, oriented. No asterixis (the flapping hand tremor of advanced uremia), no pericardial rub. Lungs clear; trace ankle edema. The toe site has healed. On the inner left upper arm there is a healed puncture mark where the PICC entered and, above it, a firm, non-tender cord along the vein — a vein that clotted around the catheter.

Medications

No SGLT2 inhibitor was ever started.

Today's labs

Reading it the way the attending does. G4 A3 — every G4 cell on the KDIGO heat map is red. BUN:creatinine 18:1. A bicarbonate of 17 with a normal anion gap (138 − [110 + 17] = 11, or 12 after adding 2.5 per g/dL of albumin below 4) is the metabolic acidosis of CKD: too few nephrons to excrete the day's acid, with chloride filling the space. Phosphorus 6.1, PTH 310 and a low 25-OH vitamin D are CKD mineral and bone disorder (CKD-MBD): the kidney holds on to phosphate and makes less active vitamin D, and the parathyroid glands answer with more PTH. Iron studies for the hemoglobin of 10.6 go on the four-week labs.

Three things start before she leaves. Oral sodium bicarbonate twice daily, because the bicarbonate has now been low twice: KDIGO 2012 suggested alkali below 22, and KDIGO 2024 frames treatment around acidosis with potential clinical consequences, giving under 18 as an example — at 17 she qualifies by either rule. The renal dietitian for phosphorus. Cholecalciferol (nutritional vitamin D) for the deficiency. Calcitriol (active vitamin D) is not started — in non-dialysis CKD it is reserved for severe, progressive hyperparathyroidism once phosphate and vitamin D are dealt with — and a phosphate binder waits for a second high value. The conversation about what comes next is booked for four weeks, with her son there.

Pause — commit before the reveal

Four weeks later Joan returns with her husband and her son, Mark, 41.

Part 2 — Data

Answers for this section: Q5 · Q6

The four-week visit

Ferritin 70 with a saturation of 16% is iron deficiency; oral iron starts today. Her KFRE is 35% at 2 years and 74% at 5 years — past the 10% line for multidisciplinary care, just under the 40% line, in a woman who is G4 and losing 6–7 points a year. She is independent, healing well, with no heart failure and no cancer. Mark asks the question nobody has asked her yet: "Could I give her one of mine?"

Pause — commit before the reveal

Two weeks later Joan and her husband sit through the kidney-options class. If she needs dialysis before a transplant she leans toward in-center hemodialysis — "I don't want my kitchen turned into a supply room." She is not immune to hepatitis B, so vaccination starts now, while the response is better than it will be on dialysis. The transplant center books her evaluation, Mark asks for the living-donor packet, and the access surgeon will see her next month.

Pause — commit before the reveal

Part 3 — Course and Decisions

Answers for this section: Q7 · Q8

Vein mapping finds the left basilic vein — the one the PICC used — narrowed and scarred, the forearm cephalic vein too small for the usual wrist fistula, and the left cephalic vein at the elbow a good size; a left upper-arm fistula is planned. The PICC cost her one vein, not the arm. A letter goes to the outside hospital, and every chart she has now carries one line: Left arm — no IVs, no blood draws, no blood-pressure cuffs.

Ten weeks after the first visit Joan brings two things to clinic: a printed "kidney diet" from a website, and her mother.

Her mother, Mrs. Agnes Theisen, 88, lives with Joan and her husband. The same primary-care clinic referred her after Joan's admission frightened the family, and she is on the same clinic list this morning. Agnes has moderate Alzheimer dementia — she knows her family but cannot manage her pills and needs help to bathe and dress — and heart failure that has put her in the hospital twice this year. Her eGFR has drifted from 17 a year ago to 14 today (creatinine 3.1 mg/dL). She eats small meals and has no itching, nausea or new confusion; potassium 4.9, bicarbonate 21. Joan holds her health-care power of attorney. Asked what matters to her, Agnes says, "My own bed. Joan's cooking."

The attending asks herself the surprise question — would I be surprised if Agnes died in the next 12 months? — and the honest answer is no.

Pause — commit before the reveal

Resolution and Teaching Points

Answers for this section: W1 · W2 · Q3 · Q4 · Q5 · Q6 · Q7 · Q8

Agnes, Joan and the nephrology team talked twice more, once with the palliative-care nurse. Agnes, with Joan beside her as her health-care agent, chose conservative care: her bicarbonate tablets and diuretic, a low-salt diet built around Joan's cooking, an advance directive on the refrigerator (no dialysis, no CPR, comfort first), and a nephrology visit every two months that asks first about appetite, itch, sleep and breath. A year later she is still at home.

Joan's fistula was created three months after her first visit and was ready to use four months later. Mark's donor evaluation is still under way. Sixteen months after the first visit, at an eGFR of 8, the nausea came back with itching and a 4-kg weight loss that bicarbonate and diet did not fix — the symptoms a symptom-driven start waits for — and she started in-center hemodialysis through her fistula: no catheter, no emergency, no hospital stay. The late referral cost her an SGLT2 inhibitor and one vein. It did not cost her the choice.

Clinical Pearl — Refer at the first trigger, not the last Refer for eGFR below 30, validated kidney-failure risk above the referral range, or other current KDIGO circumstances such as substantial albuminuria, significant progression or persistent complications. Send the cause, trend, urine results and medication list. Preserve suitable veins through an individualized access plan.

Clinical Pearl — The SGLT2 window closes at 20 SGLT2 inhibitors are started at an eGFR of 20 or higher and continued below 20 until dialysis or transplant. Joan was 29 two years ago and 22 a year ago; at 17 the window had closed. A late referral costs drugs, not just time.

Clinical Pearl — Start for symptoms, not for a number Starting dialysis at an eGFR of 10–14 rather than 5–7 gave no survival benefit in the IDEAL trial . Treat what is treatable first — acidosis, anemia, volume, a drug — and start when uremic symptoms or complications outrun medical treatment.

Clinical Pearl — Conservative kidney management is active care Symptoms, acidosis, anemia, potassium and fluid are still treated; an advance care plan is written; palliative care joins . The surprise question — would I be surprised if this patient died in the next 12 months? — is one the clinician asks themself. A "no" opens a conversation; it does not decide it.

Pitfall — A PICC in CKD G3–G5 Six weeks of IV antibiotics through an arm PICC can cost a future fistula . Call nephrology first: a small-bore tunneled internal jugular catheter spares the arm veins, and KDOQI 2019 asks that all veins be protected from G3 onward .

Pitfall — Waiting until the patient is "ready for the dialysis talk" Preparation is not a start. Teaching, transplant evaluation and access planning take months; waiting for an eGFR under 15 turns a choice into an emergency.

Concept Links

Answers for this section: W1 · W2 · Q3 · Q4 · Q5 · Q6 · Q7 · Q8

Assigned reading: the explanations in this case and the question-linked course evidence guide. The objective map distinguishes tested decisions from concepts taught in explanations.

Concepts: aki-22, ckd-09, ckd-16, ckd-21, ckd-22, ckd-23, ckd-24, ckd-25, ckd-27, structural-25, structural-26.