For millions of Americans with chronic kidney disease (CKD), the risk of developing atherosclerotic cardiovascular disease (ASCVD) or progressing to kidney failure looms large—but many never receive the specialized care that could make a critical difference. New research presented at the National Kidney Foundation Spring Clinical Meetings in New Orleans last month reveals a troubling gap: a significant number of patients at intermediate or high risk for ASCVD or kidney failure are never referred to nephrology, despite evidence suggesting they could benefit from early intervention.
The findings, led by Sharlene Shirali, a medical student at the University of California, San Francisco, and her colleagues, highlight how systemic barriers and clinical triage practices may be leaving vulnerable patients behind. According to the study, more than half of the 7,364 primary care patients with CKD—defined as an estimated glomerular filtration rate (eGFR) between 15 and 59 mL/min/1.73 m² or a urine albumin-to-creatinine ratio greater than 30 mg/g—had intermediate or high risk for developing ASCVD within the next decade. Yet, none of these patients had ever been referred to a nephrologist between 2021, and 2025.
This disparity is not just a matter of missed opportunities; it reflects deeper challenges in how primary care providers prioritize referrals. “At the systems level, barriers to nephrology referrals include increased wait times and limited nephrology specialty capacity,” Shirali explained. “referrals may be prioritized for patients with very advanced CKD, rapidly progressive disease, or a higher disease burden. This triaging by primary care providers may lead to lower referral rates, particularly for patients who are regarded as clinically stable.”
Who Is at Risk—and Who Is Missing Out?
The study’s patient cohort was diverse, with 53.3% men and 35.3% Hispanic or Latino, reflecting the broader population at risk for CKD and its complications. Researchers used two validated risk assessment tools: the PREVENT equation to estimate ASCVD risk and the Kidney Failure Risk Equation to predict the likelihood of kidney failure within two years. The PREVENT equation, developed by the American Heart Association, incorporates factors such as age, sex, blood pressure, cholesterol levels, diabetes status, smoking history, and kidney function to calculate a patient’s 10-year risk of ASCVD. The Kidney Failure Risk Equation, meanwhile, uses age, sex, eGFR, and urine albumin-to-creatinine ratio to estimate the risk of kidney failure.
While more than 90% of patients in the study had low risk for kidney failure within two years, the data revealed a stark contrast when it came to ASCVD risk. Nearly half (48.3%) of the patients faced intermediate risk, and 9.1% were at high risk for developing ASCVD within the next decade. Yet, despite these elevated risks, nephrology referrals remained rare. The study suggests that targeted nephrology consults could help prevent ASCVD and kidney failure in these high-risk patients, but current referral practices often overlook them.
Barriers to Care: Why Are Referrals Lagging?
Shirali and her team identified several systemic barriers contributing to the referral gap. First, the limited capacity of nephrology specialty care means that providers often prioritize patients with the most advanced or rapidly progressing disease. Second, long wait times for nephrology consultations can deter primary care providers from referring patients who are not yet symptomatic or whose disease appears stable. Finally, the complexity of managing both CKD and ASCVD may lead to a lack of clear guidelines or protocols for when to refer patients with intermediate risk.
“By modeling the potential impact of nephrology referrals on cardiovascular and end-stage kidney disease risks in the entire population and subgroups of interest, we can prioritize referrals for patients most likely to benefit from nephrology comanagement,” Shirali said. “This approach could support equitable allocation of specialty care and improve outcomes for those at highest risk.”
What Does This Mean for Patients and Providers?
For patients, the message is clear: if you have CKD and are at intermediate or high risk for ASCVD or kidney failure, you may want to proactively discuss your care plan with your primary care provider. Ask whether a nephrology referral is appropriate, even if your disease seems stable. For providers, the findings underscore the need for more nuanced referral criteria and better integration of risk assessment tools into clinical practice.
Looking ahead, Shirali and her colleagues are calling for further research to identify which patients would benefit most from earlier nephrology referrals. They also advocate for health systems to develop strategies that address the capacity and wait-time challenges, ensuring that all patients—regardless of disease stage—have access to the care they need.
The Next Steps: What’s on the Horizon?
The National Kidney Foundation Spring Clinical Meetings, held May 6–10 in New Orleans, served as a platform for discussing these and other critical issues in nephrology. The next major checkpoint for updates on this research will likely be future presentations at national meetings or publications in peer-reviewed journals. In the meantime, patients and providers are encouraged to stay informed about evolving guidelines and risk assessment tools.
If you or a loved one is living with CKD, it’s significant to stay engaged in your care plan. Ask questions, seek second opinions, and advocate for the level of care that best matches your risk profile. For more information, visit the National Kidney Foundation’s resources on CKD and ASCVD risk assessment.
Have you or someone you know faced challenges accessing nephrology care? Share your experiences in the comments below, and help raise awareness about this critical issue.
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