• Kellie Hunter Campbell, William Dale, Nicole Stankus, and Greg A Sachs.
• Section of Geriatrics, University of Chicago, Chicago, IL 60637, USA. kcampbel@medicine.bsd.uchicago.edu
• J Gen Intern Med. 2008 Mar 1; 23 (3): 329336329-36.

BackgroundChronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults.ObjectiveThis scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD.ResultsWhile age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD.ConclusionsMore information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.

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