When considering the overwhelming prevalence of kidney disease, nephrologists and transplant surgeons alike agree that early referral is key to slowing the progression of renal disease and possibly avoiding the need for dialysis and transplantation altogether. "There are 350,000 dialysis patients in the country now," explains Dr. Tom Ozbirn, partner with Nephrology Associates. "There's ten times that many patients who have chronic kidney disease that are potential dialysis patients. Transplant is the best option, but unfortunately, there are thousands of people on the list waiting for a kidney – over 2,400 people on the list at UAB alone. They do 300 transplants per year. We are now putting people on the transplant list that we know are going to die before they're called. It's a catastrophic thing. "So we're trying to maximize efficacy of pre-dialysis evaluation," he continues. "We're trying to get patients to nephrologists and … get them thinking about kidney disease earlier. We think if we get these patients earlier and we follow them for longer, that we might impact disease progression to delay, possibly even prevent, them reaching end stage renal disease, prevent them from ever needing a transplant, prevent them from ever needing dialysis." Ozbirn urges primary physicians to be aware of kidney disease and to know who is most at risk. Diabetics need to be watched particularly carefully, he says. "Forty to 50 percent of Type 2 diabetics will have some level of kidney disease. Ten percent of Type 2 diabetics reach end stage. Diabetes represents 50 percent of all of our new starts on dialysis." When physicians wait until a patient's creatinine levels reach 4, 5 or 6, the patient is already at or near the need for dialysis, explains Ozbirn. "A creatinine of 1.5 in most women is abnormal. A creatinine that is two in men is not normal. It would be more appropriate to refer them far, far earlier in their care." Dr. Denyse Thornley-Brown, associate professor of medicine in the Division of Nephrology at UAB, agrees. "From the point of view of a nephrologist who sees a lot of people who end up on dialysis, I think the importance of early referral allows people to plan their lives. It allows patients to make decisions. And the worst thing we have to deal with is when people are referred very late and we have to do the dialysis talk right away. When we see people early … it can allow us to start educating people early. Often they have to hear things several times. They can learn more about the dietary restrictions they need as their kidneys fail, and it can allow them to have more participation and more choice in how they want to treat their end stage renal disease. For someone to get a transplant, they need to be educated early, they need to get evaluated, they need to seek potential donors, and all that takes time. If they're going to do dialysis, they're going to need minor surgery, so they can do whichever type of dialysis they would choose. So all of these things are good reasons to see people early." In addition to monitoring kidney function in diabetics, Ozbirn encourages primary care physicians to monitor blood pressure (140/80, once an acceptable level, is now considered pre-hypertension). "Our target blood pressures are now lower. And we think that is kidney-friendly, if you will," he says. "Blood pressure is a cause of kidney damage, particularly in the African American population. There is something relatively nephrotoxic about high blood pressure in blacks that makes them more at risk for kidney damage, presumably solely as a result of high blood pressure. At the very minimum, hypertensives should have screening labs at least once, maybe twice a year." Ozbirn and Thornley-Brown agree that awareness is growing, and they are seeing a trend toward earlier referrals already. They find that encouraging. "Once they reach end-stage, I can provide dialysis and I can help their family members find donors," says Ozbirn, "but I see it as my role is to try my very, very best to prevent them from having progressive kidney disease."