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referral criteria from primary care - kidney disease

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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:

    • GFR less than 30 ml/min/1.73 m2 (GFR category G4 or G5), with or without diabetes

    • ACR 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated

    • ACR 30 mg/mmol or more (ACR category A3), together with haematuria

    • sustained decrease in GFR of 25% or more, and a change in GFR category or sustained decrease in GFR of 15 ml/min/1.73 m2 or more within 12 months

    • hypertension that remains poorly controlled despite the use of at least 4 antihypertensive drugs at therapeutic doses

    • known or suspected rare or genetic causes of CKD

    • suspected renal artery stenosis

  • 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 (July 2014). Chronic Kidney Disease - Early identification and management of chronic kidney disease in adults in primary and secondary care
  2. The Renal Association (2007).UK CKD Guidelines
  3. The Renal Association UK (March 2014). The management of hyperkalaemia in adults.

Last reviewed 01/2018

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