Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

The nephrologist as primary care clinician in patients with end-stage renal disease

Jean L Holley, MD, FACP
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD


The practice of nephrology encompasses both primary and specialty medical care. Consultative care is primarily given to patients with newly diagnosed kidney disease, including acute kidney injury, hematuria, or proteinuria. Nephrologists also commonly provide primary care or nonrenal related medical care to patients undergoing chronic dialysis. As an example, the initial evaluation of chest pain in the dialysis patient is most often performed by the nephrologist who also oversees renal replacement therapy.

Factors involved in the debate over primary care provided by a nephrologist include [1-10]:

The time and training required for primary care

The lack of adequate reimbursement for nondialysis-related care

The projected lack of available nephrologists

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Sep 25, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Latos D. Should the nephrologist be a primary care physician? Combining nephrology and primary care: not a black and white issue. Nephrol News Issues 1994; 8:19.
  2. Lazarus JM. Should the nephrologist be a primary care physician? Triage expert or primary care physician? Nephrol News Issues 1994; 8:19, 21, 26.
  3. Owen WF Jr, Norris K. Nephrologists should be the primary care physician for minority, poor dialysis patients. Nephrol News Issues 1994; 8:54.
  4. Ad Hoc Committee on Nephrology Manpower Needs, 1996.
  5. McGinnis C, Day LM, Pristave R. What are the options for nephrologists under capitation? Nephrol News Issues 1996; 10:21.
  6. Farley DO. Financing of end-stage renal disease care: past, present, and future. Adv Ren Replace Ther 1994; 1:24.
  7. Holley JL. Nephrologists as primary care providers: a review of the issues. Am J Kidney Dis 1998; 31:574.
  8. Zimmerman DL, Selick A, Singh R, Mendelssohn DC. Attitudes of Canadian nephrologists, family physicians and patients with kidney failure toward primary care delivery for chronic dialysis patients. Nephrol Dial Transplant 2003; 18:305.
  9. Berns JS, Szczech LA. What is the nephrologist's role as a primary care provider? We all have different answers. Clin J Am Soc Nephrol 2007; 2:601.
  10. Holley JL. General medical care of the dialysis patient: Core Curriculum 2013. Am J Kidney Dis 2013; 61:171.
  11. Kitahata MM, Koepsell TD, Deyo RA, et al. Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival. N Engl J Med 1996; 334:701.
  12. Radecki SE, Blagg CR, Nissenson AR, et al. End-stage renal disease and the practice of nephrology. Am J Kidney Dis 1989; 14:402.
  13. Bender FH, Holley JL. Most nephrologists are primary care providers for chronic dialysis patients: results of a national survey. Am J Kidney Dis 1996; 28:67.
  14. Schwartz JS, Lewis CE, Clancy C, et al. Internists' practices in health promotion and disease prevention. A survey. Ann Intern Med 1991; 114:46.
  15. Rush H, Neugarten J, Coco M. Women's health issues in a dialysis population. Clin Nephrol 2000; 54:455.
  16. Nespor SL, Holley JL. Patients on hemodialysis rely on nephrologists and dialysis units for maintenance health care. ASAIO J 1992; 38:M279.
  17. Holley JL, Nespor SL. Nephrologist-directed primary health care in chronic dialysis patients. Am J Kidney Dis 1993; 21:628.
  18. Nissenson AR. What common practices in dialysis units can be altered to improve patient care? Semin Dial 2004; 17:12.
  19. Hogan SL, Mandelkehr L, Self EM, Falk RJ. Reduction in length of stay and costs for hospitalized hemodialysis patients cared for by nephrologists as compared to internists (Abstract). J Am Soc Nephrol 1996; 7:1388.
  20. Kshirsagar AV, Hogan SL, Mandelkehr L, Falk RJ. Length of stay and costs for hospitalized hemodialysis patients: nephrologists versus internists. J Am Soc Nephrol 2000; 11:1526.
  21. Ifudu O, Dawood M, Homel P, Friedman EA. Excess morbidity in patients starting uremia therapy without prior care by a nephrologist. Am J Kidney Dis 1996; 28:841.
  22. Schmidt RJ, Domico JR, Sorkin MI, Hobbs G. Early referral and its impact on emergent first dialyses, health care costs, and outcome. Am J Kidney Dis 1998; 32:278.
  23. Ellis PA, Reddy V, Bari N, Cairns HS. Late referral of end-stage renal failure. QJM 1998; 91:727.
  24. McClellan WM, Soucie JM, Flanders WD. Mortality in end-stage renal disease is associated with facility-to-facility differences in adequacy of hemodialysis. J Am Soc Nephrol 1998; 9:1940.
  25. Metcalfe W, Khan IH, Prescott GJ, et al. Can we improve early mortality in patients receiving renal replacement therapy? Kidney Int 2000; 57:2539.
  26. Plantinga LC, Fink NE, Sadler JH, et al. Frequency of patient-physician contact and patient outcomes in hemodialysis care. J Am Soc Nephrol 2004; 15:210.
  27. Johnson CA, McCarthy J, Bailie GR, et al. Analysis of renal bone disease treatment in dialysis patients. Am J Kidney Dis 2002; 39:1270.
  28. Kawaguchi T, Karaboyas A, Robinson BM, et al. Associations of frequency and duration of patient-doctor contact in hemodialysis facilities with mortality. J Am Soc Nephrol 2013; 24:1493.
  29. Mentari EK, DeOreo PB, O'Connor AS, et al. Changes in Medicare reimbursement and patient-nephrologist visits, quality of care, and health-related quality of life. Am J Kidney Dis 2005; 46:621.
  30. Slinin Y, Guo H, Li S, et al. Association of provider-patient visit frequency and patient outcomes on hemodialysis. J Am Soc Nephrol 2012; 23:1560.
  31. Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Physician visits and 30-day hospital readmissions in patients receiving hemodialysis. J Am Soc Nephrol 2014; 25:2079.
  32. Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Medicare Reimbursement Reform for Provider Visits and Health Outcomes in Patients on Hemodialysis. Forum Health Econ Policy 2014; 17:53.
  33. Winkelmayer WC, Owen W, Glynn RJ, et al. Preventive health care measures before and after start of renal replacement therapy. J Gen Intern Med 2002; 17:588.
  34. Kausz AT, Guo H, Pereira BJ, et al. General medical care among patients with chronic kidney disease: opportunities for improving outcomes. J Am Soc Nephrol 2005; 16:3092.
  35. Choudhury D, Luna-Salazar C. Preventive health care in chronic kidney disease and end-stage renal disease. Nat Clin Pract Nephrol 2008; 4:194.
  36. Chettiar A. Management of primary care issues common to CKD and ESRD patients: a brief primer for the nephrology provider. Adv Chronic Kidney Dis 2014; 21:371.
  37. Holley JL. Preventive care in end-stage renal disease. In: Handbook of Dialysis Therapy, 5th ed., Nissenson AR, Fine RN (Eds), Elsevier, Philadelphia 2017. p.1107.
  38. McIntyre C, McQuillan R, Bell C, Battistella M. Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy. Am J Kidney Dis 2017; 70:611.