Nephrologist referral and kidney transplant evaluation should occur now. This patient has severe chronic kidney disease (CKD) and will likely require dialysis within the next 1 to 2 years. All patients with stage G4 or G5 CKD should be referred to a nephrologist for evaluation and optimization of metabolic parameters and preparation for dialysis. Because proper preparation for dialysis can take many months, especially if an arteriovenous fistula must be created for hemodialysis, timely referral is important. Hemodialysis and peritoneal dialysis have similar clinical outcomes; choice of modality should be guided by patient preference, willingness, and ability to participate in self-care. All patients who are willing to consider kidney transplant and do not have absolute medical contraindications should be referred for transplant evaluation once their estimated glomerular filtration rate is below 20 mL/min/1.73 m2 because they are then eligible to be placed on a waiting list for a transplant. This is especially important because the waiting list is several years long in most parts of the United States, and early listing maximizes the chances of surviving until transplant. Also, if a living donor is identified, it is possible that the patient may receive a preemptive transplant before requiring dialysis. It is important to refer patients with CKD to a nephrologist early in the course of the disease for evaluation because late referral is associated with increased mortality.
Waiting to refer to a nephrologist for 6 months will delay proper preparation for dialysis therapy, dialysis access placement, and transplant evaluation.
Rechecking serum creatinine in 2 weeks is not indicated because this patient has long-standing CKD that is unlikely to be significantly improved after 2 weeks, and this approach will unnecessarily delay referral to a nephrologist.
Continuing current management is incorrect because the patient requires timely preparation for renal replacement therapy and transplant referral, and delays in nephrology referral for patients with severe CKD are associated with increased risk of mortality.