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Nephrology


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)

Please note this is not an exhaustive list of all conditions for outpatient services and does not exclude consideration for referral unless specifically stipulated in the CPC out of scope section. 

The following are not routinely provided in a public Nephrology service.

  • Enuresis (nocturnal incontinence) in paediatrics