There will be differing local pathways and processes for accessing renal services. Frequently advice by email or telephone may help in reaching a decision. Follow local protocols when and where available. Seek specialist advice where patients fall outside protocols. What follows is general guidance about referral thresholds which may help inform the decision to refer to or seek further advice from renal services.
|According to eGFR (ml/min/1.73m2)|
|<15||Usually immediate referral or discussion (see CKD stages G4 and G5 for possible exceptions)|
|15-29||Usually require referral or discussion with renal services, particularly if newly discovered.|
|30-59||Routine referral indicated if progressive renal impairment as defined by:
|60+||Referral not required unless other evidence of kidney disease (e.g. likely genetic diagnosis, associated urinary abnormalities) or rapidly progressive renal impairment.|
|Other indications for referral|
|Acute kidney injury||Immediate referral/discussion - most patients with acute kidney injury unless the cause and treatment are obvious and deliverable.|
|Proteinuria||Routine referral - urinary ACR>70 or PCR>100mg/mmol; or ACR>30 or PCR>50mg/mmol with microscopic haematuria
Urgent referral - Heavy proteinuria with low serum albumin (nephrotic syndrome) or if associated with rapidly progressive renal impairment.
|Haematuria||Visible haematuria with negative urological investigations or with strong features of renal disease
Invisible haematuria with proteinuria as above
|Hypertension||Immediate referral - malignant hypertension
Routine referral - uncontrolled (>150/90) BP despite 4 agents at therapeutic doses in a patient with CKD
|Systemic illness||Suspicion of renal involvement from a systemic illness (e.g myeloma, vasculitis, sarcoidosis) should lead to urgent referral or discussion.|
|Renal outflow obstruction||Should usually be referred to the urologists unless urgent medical intervention is needed for the metabolic effects of renal failure e.g. hyperkalaemia, symptomatic uraemia or fluid overload|
Information that it is valuable to send with the referral
- General medical history – particularly noting urinary symptoms, previous blood pressures, results of urine testing, significant diagnoses
- Medication history – including non-prescribed and over-the-counter drugs such as non-steroidal anti-inflammatory drugs (NSAIDs), herbal remedies
- Family history – Where relevant
- Examination – Be particularly vigilant for a palpable bladder, especially in older men with a history of lower urinary tract symptoms.
- Urine dipstick result for haematuria and quantitation of proteinuria by ACR or PCR
- Blood tests – Full blood count, urea and electrolytes. HbA1c if diabetic. If available, calcium, albumin, phosphate, cholesterol.
- Previous tests of renal function (with dates) back to normal renal function if possible (unless electronically available in specialist centre).
- Imaging – results of renal imaging if undertaken (according to local circumstances, pre-ordering may speed assessment)