Referral

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.

  When to refer to specialist services (summary)
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:
 
  • Sustained decrease in GFR of ≥25% AND a change in GFR category within 12 months
    OR
  • Sustained decrease in GFR of ≥15 ml/min/1.73m2 within 12 months

    Consider referral if:

  • Unexplained non-visible haematuria (see Haematuria)
  • Proteinuria (i.e. ACR>70 or PCR>100 mg/mmol) (see proteinuria)
  • Unexplained anaemia (i.e. Hb<110 g/L), abnormal potassium, calcium or phosphate
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.

Further info about proteinuria

Haematuria Visible haematuria with negative urological investigations or with strong features of renal disease

Invisible haematuria with proteinuria as above

Further info about haematuria

Hypertension Immediate referral - malignant hypertension
Routine referral - uncontrolled (>150/90) BP despite 4 agents at therapeutic doses in a patient with CKD

Further info about hypertension in 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)

Guidelines

NICE accredited clinical practice guidelines 

Available here

22nd Annual Report

Analyses about care provided to patients at UK renal centres.

Read the report

UKRR AKI Report

A report on the nationwide collection of AKI warning test scores. 

Read the report