U.S. Department of Health and Human Services
National Kidney Disease Education Program Logo

Contact Us

Health Information Center


 Alternate Versions


Nephrology Referral Form

NKDEP encourages collaborative management and communication between primary care providers (PCPs) and nephrologists to help improve patient outcomes.

The interactive Nephrology Referral Form  (PDF, 162 KB) is designed to help referring PCPs share important patient data with the consulting nephrologist. The form can be saved to a computer, edited, and shared electronically with the nephrologist.

Remember to save the form to your computer before entering data. Also, to comply with the Health Insurance Portability and Accountability Act of 2002, please protect the personal health information contained in the completed form.

Rationale for Data Inclusion

The form provides fields for entering data that are likely to be useful for patient evaluation. The following information provides the rationale for why this information is important.


Presence or absence of diabetes is critical to establishing an etiology for kidney disease and risk for progression. Duration of diabetes is useful for determining the likelihood that the patient's chronic kidney disease (CKD) is caused by diabetes.


Non-kidney complications can help in determining whether kidney disease is a complication of diabetes or a co-existing medical problem. In patients with diabetes and CKD who have proteinuria and retinopathy, diabetes is the likely cause of CKD. The absence of retinopathy or other complications increases the likelihood of a non-diabetic etiology and may indicate the need for a biopsy.


A very important prognostic marker in patients with CKD. The duration and quantity of albuminuria are critical to assessing the patient's current status and prognosis. Use mg albumin/g creatinine.


May indicate the presence of an inflammatory process.


The rate of decline in kidney function varies from patient to patient, but CKD tends to progress at a constant rate in most individuals. Thus, the availability of serial measurements of eGFR over a long period of time provides information that can be used to educate the patient about his/her prognosis. A decrease in the rate of decline of eGFR may reflect response to therapy.


High blood pressure, along with proteinuria (using albuminuria as the marker) and rate of loss of kidney function, is an important prognostic indicator. Control of hypertension is also a key opportunity to reduce the rate of progression of CKD.

Page last updated: October 10, 2012


Contact Us

Health Information Center