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Proteinuria

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


 

PAEDIATRIC

NB: Please call your local nephrology service if there is any doubt regarding the urgency of referral for an unwell patient

Congenital anomalies of the kidney and urinary tract

  • Poor urinary stream in neonate / suspected posterior urethral valves
  • Previously undiagnosed kidney impairment in association with congenital structural malformations

Haematuria / glomerulonephritis

  • Suspected glomerulonephritis (ie haematuria and proteinuria) with acute kidney injury, hypertension or where the patient is systemically unwell

Hypertension

  • Severe hypertension with any of the following concerning features:
    • headache
    • confusion
    • blurred vision
    • retinal haemorrhage
    • reduced level of consciousness
    • seizures
    • proteinuria
    • papilloedema
    • signs of heart failure
    • chest pain


Proteinuria / nephrotic syndrome

  • Nephrotic syndrome (proteinuria with urine PCR > 200g/mol) with any of the following concerning features:
    • significant peripheral oedema
    • signs of pulmonary oedema
    • severe hypertension
    • signs of DVT/PE
    • infection
    • acute kidney injury

Kidney stones

  • Suspected urolithiasis / nephrolithiasis with infection or severe pain
  • Suspected urinary retention/obstruction (eg anuria, oliguria)

Other

  • Any acute kidney injury or significant decline in kidney function where the treating doctor believes the patient requires urgent hospital care
  • Oliguria/anuria
    • Severe acute electrolyte disturbance for example:
    • hyperkalemia with K+ > 6.5 mmol/L OR > 6.0 mmol/L with ECG changes
    • hypokalemia with K+ < 2.5 mmol/L OR < 3.0mmol/L with symptoms
  • severe metabolic acidosis (HCO3 < 15mmol/L)
  • Kidney transplant recipients with an acute decline in kidney function
  • Suspected glomerulonephritis (proteinuria and haematuria) associated with acute kidney injury

 

ADULT

NB: Please call your local nephrology service if there is any doubt regarding the urgency of referral for an unwell patient

Acute decline in kidney function

  • Any acute kidney injury or significant decline in kidney function where the treating doctor believes the patient requires urgent hospital care (especially if evidence of abrupt increase in serum creatinine by > 50% of baseline)
  • Oliguria/anuria
  • Severe acute electrolyte disturbance for example:
    • hyperkalemia with K+ > 6.5 mmol/L OR > 6.0 mmol/L with ECG changes
    • hypokalemia with K+ < 2.5 mmol/L OR < 3.0mmol/L with symptoms
    • severe metabolic acidosis (HCO3 < 15mmol/L)
  • Kidney transplant recipients with an acute decline in kidney function (e.g. > 20% increase in serum creatinine)
  • Suspected glomerulonephritis (proteinuria and haematuria) associated with acute kidney injury

Chronic kidney disease

  • Severe acute electrolyte disturbance for example:
    • hyperkalemia with K+ > 6.5 mmol/L OR > 6.0 mmol/L with ECG changes
    • hypokalemia with K+ < 2.5 mmol/L OR < 3.0mmol/L with symptoms
    • severe metabolic acidosis (HCO3 < 15mmol/L)
  • Severe hypertension especially when accompanied with declining kidney function
  • Patients with severe uraemic symptoms or signs
  • Evidence of acute fluid overload or heart failure in a patient with known CKD
  • Kidney transplant recipients with acute intercurrent illness
  • Peritoneal or haemodialysis patients with acute issues or problems with dialysis access (eg vascular access issues or peritoneal dialysis catheter issues)
  • Peritoneal dialysis patients with suspected peritonitis (abdominal pain, cloudy dialysis fluid)

Cystic kidney disease

  • Significant cyst haemorrhage, suspected septicaemia related to cyst infection, suspected rupture of berry aneurysm

Glomerulonephritis

  • Suspected glomerulonephritis (proteinuria and haematuria) with acutely declining kidney function or patient systemically unwell

Haematuria

  • Severe macroscopic haematuria

Hypertension

  • Hypertensive emergency (for example BP > 220/140)
  • Severe hypertension with systolic BP > 180mmHg with any of the following concerning features:
    • headache
    • confusion
    • blurred vision
    • retinal haemorrhage
    • reduced level of consciousness
    • seizures
    • proteinuria
    • papilloedema
    • signs of heart failure
    • chest pain

If suspected pregnancy induced hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric services where possible.

Nephrolithiasis – recurrent

  • Suspected urolithiasis / nephrolithiasis with infection or severe pain
  • Suspected urinary retention/obstruction (eg anuria, oliguria)

Proteinuria

  • Nephrotic syndrome (proteinuria > 3.5 grams/24 hours OR urine ACR > 300mg/mmol* or PCR > 300g/mol*) with any of the following concerning features:
    • significant peripheral oedema
    • signs of pulmonary oedema
    • severe hypertension
    • signs of DVT / PE
    • infection
    • acute kidney injury

Other

  • Kidney transplant patients with significant intercurrent illness (eg diarrhoea and vomiting)

* At the level of nephrotic range proteinuria, albumin accounts for 60-70% of total urinary protein. Within the CPC, ACR > 300mg/mmol OR PCR > 300g/mol has been used for simplicity and ease of application.

Quantifying proteinuria (Source – Tasmanian Health 2018):

  • Urine ACR (random or first morning) is generally a sufficient screen for albuminuria/microalbuminuria in diabetic and non-diabetic populations and is a useful test in most renal clinic referrals (first morning specimens increase specificity - but not necessary).  Additional protein creatinine ratio testing can assist with diagnostic evaluation.
  • 24-hour quantification: Where urine ACR is significantly elevated (>100mg/mmol) consideration can be given to 24-hour urine protein collections (not generally required in most low-level albuminuria but is more likely to be helpful in those with suspected nephrotic syndrome)
  • Low level albuminuria/proteinuria can occur transiently during fever, cardiac failure, after strenuous exercise (usually no more than trace on dipstick)
  • Haematuria and proteinuria present together is strongly suggestive of a glomerular source for haematuria

As per KHA guidelines, persistent significant albuminuria (ACR > 30mg/mmol) should be referred. Referral is not necessary for a urine ACR < 30mg/mmol with no haematuria. 

  • Refer to Healthpathways or local guidelines

 

Clinician resources

Patient resources

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Nephrotic range proteinuria* (urine ACR > 220mg/mmol or PCR > 350g/mol) without concerning features (see below)
    • Proteinuria (urine ACR 30-220 mg/mmol or PCR 60-350 g/mol) with a declining eGFR but without concerning features (see below)

     

    Concerning features

    • Significant peripheral oedema
    • Signs of pulmonary oedema
    • Severe hypertension
    • Signs of DVT / PE
    • Infection
    • Acute kidney injury

     

    Please call your local nephrologist if any doubt of urgency of acute referral as direct ward admission may be considered.

  • Category 2
    (appointment within 90 calendar days)
    • Sub-nephrotic macroalbuminuria (urine ACR 25-220mg/mmol for men or urine ACR 35-350mg/mmol for women or PCR 60- 350g/mol) with a stable eGFR
  • Category 3
    (appointment within 365 calendar days)
    • Asymptomatic microalbuminuria (urine ACR < 25mg/mmol for men or < 35mg/mmol for women OR PCR < 50g/mol) with other evidence of kidney disease (eg haematuria)

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention not otherwise accessible to the patient
  • For advice regarding management
  • To engage in an ongoing shared care approach between primary and secondary care
  • Reassurance for GP/second opinion
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)

2. Essential referral information Referral will be returned without this

  • Presence of comorbid conditions such as hypertension, diabetes, vascular disease or known chronic kidney disease
  • Current medications, medication history and allergies
  • Timeline of symptoms
  • Examination findings including BP, peripheral oedema, signs of pulmonary oedema
  • FBC, ELFT, urea, creatinine & eGFR results (also include previous kidney related pathology results to use as a baseline)
  • Urine albumin creatinine ratio (ACR) or urine protein creatinine ratio (PCR) (ideally early morning sample but a random sample is acceptable)
  • Urine midstream M/C/S (including testing for red cell morphology and casts preferable)

3. Additional referral information Useful for processing the referral

  • Ethnicity (Aboriginal and Torres Strait Islander population especially at risk)
  • Fasting lipid results
  • HbA1c results (for patients with diabetes)
  • Ultrasound (kidney, ureters & bladder) results

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.