58% of high-risk CKD patients never see a nephrologist

Among patients whose Kidney Failure Risk Equation (KFRE) score exceeds 10% -- meaning they have a significant probability of needing dialysis within 5 years -- only 41.5% visit a nephrologist within one year. Even among the highest-risk group (KFRE 90-100%, meaning near-certain dialysis), just 57.7% see a nephrologist within a year. This late referral is catastrophic because it means patients crash into dialysis unprepared: no fistula placement (so they start on a dangerous catheter), no transplant workup (losing years of potential waitlist time), no education about home dialysis options, and no dietary or medication optimization to slow progression. Primary care physicians are the bottleneck -- they often lack CKD-specific training, do not use KFRE calculators, and perceive no urgency until the patient is already at stage 5. Non-white patients are 2.6x more likely to be referred late. Patients over 65 are 3.5x more likely to be referred late. The structural reason: there is no CMS quality measure penalizing primary care for late nephrology referral, no financial incentive for early referral, and no integrated alert system connecting primary care EHRs to nephrology workflows when a patient's eGFR crosses a threshold.