referral criteria from primary care - chronic kidney disease (CKD)

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NICE suggest referral criteria for patients with CKD as (1):

  • people with CKD in the following groups should normally be referred for specialist assessment:

    • a 5-year risk of needing renal replacement therapy of greater than 5% (measured using the 4-variable Kidney Failure Risk Equation)
    • an ACR of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
    • an ACR of more than 30 mg/mmol (ACR category A3), together with haematuria
    • a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months
    • a sustained decrease in eGFR of 15 ml/min/1.73 m2 or more per year
    • hypertension that remains poorly controlled (above the person's individual target) despite the use of at least 4 antihypertensive medicines at therapeutic doses
    • known or suspected rare or genetic causes of CKD
    • suspected renal artery stenosis

  • Refer children and young people with CKD for specialist assessment if they have any of the following:
    • an ACR of 3 mg/mmol or more, confirmed on a repeat early morning urine sample
    • haematuria
    • any decrease in eGFR
    • hypertension
    • known or suspected rare or genetic causes of CKD
    • suspected renal artery stenosis
    • renal outflow obstruction

  • people with CKD and renal outflow obstruction should normally be referred to urological services, unless urgent medical intervention is required - for example, for the treatment of hyperkalaemia, severe uraemia, acidosis or fluid overload
More detailed guidance regarding nephrology referrals was previously stated as (2):
  • Immediate review
    • if suspected acute renal failure (ARF)
    • if ARF superimposed on CKD
    • if newly detected ERF (GFR < 15 mL/min/1.73 m2)
    • accelerated or malignant phase hypertension with suspicion of underlying kidney disease (or if there is no specialist hypertension service available locally)
    • hyperkalaemia, serum potassium >= 6.5 mmol/L (3)
  • Urgent outpatient review
    • nephrotic syndrome
    • if newly detected stage 4 (unless known to be stable) or stable stage 5 CKD
    • multisystem disease (e.g. SLE, systemic vasculitis) with evidence of kidney disease
    • hyperkalaemia, serum potassium 6.0-7.0 mmol/L (after exclusion of artefactual and treatable causes)
  • Routine outpatient review
    • refractory hypertension (defined as sustained BP >150/90 mm Hg despite combination therapy with 3 drugs from complementary classes)
    • acute deterioration in kidney function (defined as a fall of GFR of >20% or rise of serum creatinine concentration of >30% from baseline) associated with use of ACEIs or ARBs
    • proteinuria (urine protein >100 mg/mmol) without nephrotic syndrome
    • proteinuria with haematuria
    • diabetes with increasing proteinuria but without diabetic retinopathy
    • stage 3 CKD with haematuria
    • urologically unexplained macroscopic haematuria (with or without proteinuria)
    • recurrent unexplained pulmonary oedema with clinical suspicion of atherosclerotic renal artery stenosis (ARAS)
    • falling GFR (>15% fall over 12 months) with clinical suspicion of ARAS
    • PTH >70 ng/L (7.7 pmol/L) after exclusion or treatment of vitamin D deficiency
    • stable stage 4 CKD if referred
  • Conditions appropriate for GP care +/- 'virtual' nephrology support/advice
    • isolated microscopic haematuria (after negative urological evaluation where appropriate)
    • isolated proteinuria with urine protein:creatinine ratio < 100 mg/mmol
    • known or suspected polycystic kidney disease with GFR > 60 ml/min/1.73 m2
    • known reflux nephropathy in stage 1-3 without the above
    • all other stage 1-2 CKD
    • stable stage 3 or 4 CKD with no other indication for referral

     

Notes (3):

  • the threshold for emergency treatment varies, but most guidelines recommend that emergency treatment should be given if the serum K+ is >= 6.5 mmol/L with or without ECG changes

Reference:

  1. NICE (August 2021). Chronic kidney disease: assessment and management
  2. The Renal Association (2007).UK CKD Guidelines
  3. The Renal Association UK (March 2014). The management of hyperkalaemia in adults.

Last edited 09/2021 and last reviewed 09/2021

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