Referral criteria from primary care (haematuria)

• if malignancy is suspected then patients may be referred without prior investigation (1)
• first-line investigations that may be undertaken in primary care are indicated in the investigations of haematuria section of the system

Urological referral

• urological referral for further investigation is indicated in the following patients
  • all patients with macroscopic haematuria of any age
    • some patients <40 yrs with cola-coloured urine and an inter-current (usually upper respiratory tract) infection will have an acute glomerulonephritis, and a nephrology referral may be considered more appropriate if clinically suspected
  • all patients with symptomatic non-visible haematuria (s-NVH) (any age).
  • all patients with asymptomatic (a-NVH) aged ≥40 yrs

NB - in young adults (<40 yrs) who presents with cola-coloured urine and an inter-current (usually upper respiratory tract) infection, nephrology referral may be considered more appropriate since they are more likely to have acute glomerulonephritis than urological disease (1)

Nephrological referral

• nephrological referral, is indicated for patients
  • who have had a urological cause excluded
  • have not met the referral criteria for a urological assessment
• need for a nephrology referral in this situation depends on factors other than simply the presence of haematuria
• nephrology referral is recommended if there is concurrent
  • evidence of declining GFR (by >10ml/min at any stage within the previous 5 years or by >5ml/min within the last 1 year)
  • stage 4 or 5 CKD (eGFR <30ml/min)
  • significant proteinuria (ACR ≥30mg/mmol or PCR ≥50mg/mmol)
  • isolated haematuria (i.e. in the absence of significant proteinuria) with hypertension in those aged <40
  • visible haematuria coinciding with intercurrent (usually upper respiratory tract) infection
• in the event the above criteria are not met, haematuria itself (visible or non-visible) does not require nephrology referral. Such patients should however continue to be monitored in primary care (1).

The National Institute for Health and Clinical Excellence (NICE) Cancer Referral guidelines recommends urgent referral of the following patients (considering bladder and renal cancers):

• refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
  • aged 45 and over and have:
    • unexplained visible haematuria without urinary tract infection or
    • visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
  • aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test
    • note in the previous version of the guidance (4) NICE stated to "..in patients aged 50 years and older who are found to have unexplained microscopic haematuria, an urgent referral should be made" :

Reference:

• (1) Renal Association and British Association of Urological Surgeons (2008). Joint Consensus Statement on the Initial Assessment of Haematuria
• (2) National Institute for Health and Clinical Excellence (NICE) 2015. Referral guidelines for suspected cancer
• (3) The Renal Association (May 2006).UK CKD Guidelines
• (4) National Institute for Health and Clinical Excellence (NICE) 2005. Referral guidelines for suspected cancer