Nephrology - public patients

• Any acute kidney injury or significant decline in kidney function where the treating doctor believes the patient requires urgent hospital care (especially of the abrupt increase in the serum creatinine by > 50% of the baseline)
• Oliguria/anuria
• Severe acute electrolyte disturbance such as:
  • Hyperkalemia with Potassium (K⁺) >6.5mmol/L OR >6.0mmol/L with ECG Changes;
  • Hypokalemia with potassium <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 functions (e.g. > 20% increase in serum creatinine)
• Suspected glomerulonephritis (proteinuria and haematuria) associated with acute kidney injury

• Severe acute electrolyte disturbance for example:
  • hyperkalemia with potassium (K⁺) >6.5mmol/L OR >6.0mmol/L with ECG Changes
  • hypokalemia with potassium <2.5 mmol/L OR <3.0mmol/L with symptoms
  • severe metabolic acidosis (HCO₃ < 15mmol/L)
• Severe hypertension especially when accompanied with decline kidney function
• Patient with severe uraemic symptoms and 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 patient with acute issues or problems with dialysis access (e.g. vascular access issues or peritoneal dialysis catheter issues)
• Peritoneal dialysis patients with suspected peritonitis (abdominal pain, cloudy dialysis fluid)

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

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

•  Severe macroscopic haematuria

• Hypertensive emergency (for example BP >220/140)
• Severe hypertension with systolic BP > 180mmHg with any of the 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 emergency department of a facility that offers obstetric services where possible

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

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

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

Essential information 

• General Referral Information
• Presence of comorbid conditions such as hypertension, diabetes or vascular disease
• List of medicines
• BP records (if available)
• FBC
• Serial ELFTs including urea, creatinine and eGFR results
• Urine midstream M/C/S (including testing for red cell morphology and casts preferable)
• Urinalysis including albumin creatinine ratio (ACR) and protein creatinine ratio (PCR) (Ideally early morning sample, but a random sample is acceptable)
• Ultrasound (kidney, ureters and bladder) and any other available relevant imaging results

Additional referral information (useful for processing the referral)

• Timeline of symptoms
• Presence or absence of oedema
• Other supportive tests
  • If macroalbuminuria present, include ANCA, ANA, ENA and anti-DNA Abs, C3/C4 and Hepatitis B/C serology
  • If myeloma suspected, include paraprotein testing e.g. FLC, SEPP, BJP

Other useful information for management (not an exhaustive list)

• Refer to local Health pathways or local guidelines
• Consider withholding ACE- Inhibitor, ARB, diuretics, NSAIDS, metformin, sulphonylureas, SGLT2 inhibitors
• Consider dose adjustment of medication

Clinician resources

• KHA-CARI – Acute kidney injury

Patient resources

• Kidney Health Australia – Acute kidney injury

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information

• General Referral Information
• Presence of comorbid conditions such as hypertension, diabetes or vascular disease
• List of medicines
• Recent BP results
• FBC & ELFTs
• Serial urea, craetinine and eGFR results demonstrating abnormal eGFR over at least 3 months
• Urine midstream M/C/S (including testing for red cell morphology and casts preferable)
• Urinalysis including albumin creatinine ratio (ACR) and protein creatinine ratio (PCR)(Ideally early morning sample, but a random sample is acceptable)
• Ultrasound (kidney, ureters and bladder) and any other available relevant imaging results

Additional referral information (useful for processing the referral)

• Timeline of the symptoms
• Ethnicity (with Aboriginal and Torres Strait Islander population at risk)
• Family history of kidney disease
• Kidney biopsy report (if available)
• Iron studies (essential if referring for anaemia)
• Other supportive investigative tests indicated including:
  • If haematuria or macroalbuminuria present, include ANCA, ANA, ENA, and anti-DNA Abs, C3/C4 and Hepatitis B/C serology
  • If myeloma suspected, include paraprotein testing (especially if proteinuria) e.g. FLC, SEPP, BJP PTH
  • B12, Folate

Other useful information for management (not an exhaustive list)

• Refer to Healthpathways or local guidelines

At the level of nephrotic range proteinuria, albumin accounts for 60-7-% of total urinary protein. Within the CPC, ACR >300mg/mmol OR PCR > 3000g/mol has been used for simplicity and ease of application.

Before waiting 3 months to refer, it is important to establish that there is no evidence of acute kidney injury.

In absence of other referral indicators, referral is not necessary if;

• Stable eGFR > 30 mL/min/1.73 m²
• Urine ACR < 30 mg/mmol (with no haematuria)
• Controlled blood pressure

The decision to refer or not must always be individualised, and particularly in younger individuals the indication for referral may be less stringent. Discuss management issue with a specialist by letter, email, telephone in case where it may not be necessary for the person with CKD to be seen by specialists.

• Refer to Health pathways or local guidelines

Clinician resources

• KHA-CARI – Chronic kidney disease guidelines
• Chronic Kidney Disease (CKD) management in General Practice handbook developed by Kidney Health Australia
• Proteinuria Consensus Statement, 2012

Patient resources

• Kidney Health Australia
  • Fact sheets
  • Kidney disease
  • Indigenous resources

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information

• General referral information
• Presence of comorbid conditions such as hypertension, diabetes or vascular disease
• Family History of kidney disease
• List of medicines
• FBC / ELFT results
• Urine midstream M/C/S (including testing for red cell morphology and casts preferable)
• Urine albumin creatinine ratio (ACR) and protein creatinine ratio (PCR) (ideally early morning sample but a random sample is acceptable
• Ultrasound (kidney, ureters and bladder) and any other available relevant imaging results
• Recent BP results

Additional referral information (useful for processing the referral)

• Serial imaging results

Other useful information for management (not an exhaustive list)

• Refer to Healthpathways or local guidelines

Main disorder in this category

• Cystic kidney disease
• Autosomal dominant polycystic kidney disease (ADPKD)
• Autosomal recessive polycystic kidney disease
• Nephronophthisis (juvenile and adult)
• Autosomal dominant tubulointerstitial kidney disease (medullary cystic kidney disease)
• Medullary sponge kidney
• Associated with multiple malformation syndrome
  • Tuberous sclerosis complex, Lowe's syndrome, Von Hippel-Lindau Disease
• Acquired cystic kidney disease

Note that Complex cysts (Bosniak type 2 or above) should be referred to urology (where available)

• Refer to Health pathways or local guidelines

Patient resources

• Kidney Health Australia - Polycystic Kidney Disease
• Polycystic Kidney Disease Australia

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information 

• General Referral Information
• Presence of comorbid conditions such as SLE or other autoimmune condition, hypertension, diabetes or vascular disease
• List of medicines or allergies
• FBC / ELFT results
• Serial urea, creatinine & eGFR results
• Urine midstream M/C/S (including testing for red cell morphology and casts preferable)
• Urine albumin creatinine ratio (ACR) and protein creatinine ratio (PCR) (ideally early morning sample but a random sample is acceptable
• Recent BP results

Additional referral information (useful for processing the referral)

• Timeline of Symptoms
• Ethnicity (with Aboriginal and Torres Strait Islander population at risk)
• Family history of kidney disease
• Examination findings including oedema, rash, recent throat infection
• Ultrasound (kidney, ureters and bladder) and any other available relevant imaging results
• Other supportive investigative tests if indicating including:
  • ANCA, ANA, ENA and anti DNA Abs (if suspected or confirmed autoimmune condition that may impact on kidney function)
  • Hepatitis B/C serology especially if proteinuria
  • Paraprotein testing eh FLC, SEPP, BJP if myeloma suspected
  • Complement C3/C4
  • Anti GBM antibodies
  • Anti-streptococcal antibodies
• Kidney biopsy report (if previously performed)

Other useful information for management (not an exhaustive list)

• Refer to Healthpathways or local guidelines
• Please call your nephrologists if any doubt of urgency of acute referral as direct ward admission may be considered
• Please consider multi system involvement especially possibility of pulmonary haemorrhage

Clinician resources

• KDIGO Clinical Practice Guideline for Glomerulonephritis

Patient resources

• Kidney Health Australia
• Nephritis fact sheet
• Lupus nephritis fact sheet
• IgA nephritis fact sheet

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information 

• General Referral Information
• Presence of comorbid conditions such as hypertension, diabetes or vascular disease
• List of medicines
• Presence or absence of pain
• FBC / ELFT results
• Serial urea, creatinine and eGFR results
• Urine midstream M/C/S (including testing for red cell morphology and casts preferable)
• Urine albumin creatinine ratio (ACR) and protein creatinine ratio (PCR) (ideally early morning sample but a random sample is acceptable
• Ultrasound (kidney, ureters and bladder) and any other available relevant imaging results
• Recent BP result

Additional referral information (useful for processing the referral)

• Urologic Malignancy Test results (e.g. urine cytology (x3) results)

Other useful information for management (not an exhaustive list)

• Refer to Healthpathways or local guidelines
• Refer to Haematuria flowchart for guidance in determining whether to refer to urology or nephrology
• Exclusion of lower tract source of haematuria for those at risk of urological malignancy is important

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information 

• General Referral Information
• Presence of comorbid conditions such as hypertension, diabetes or vascular disease
• List of medicines including details of all treatments offered and efficacy
• FBC / ELFT and eGFR results
• Urine midstream M/C/S (including testing for red cell morphology and casts preferable)
• Urine albumin creatinine ratio (ACR) and protein creatinine ratio (PCR) (ideally early morning sample but a random sample is acceptable
• Ultrasound (kidney, ureters and bladder) and any other available relevant imaging results
• History of BP measurements including 24-hour measurements or home measurements if available
• Renal duplex report (only where renal artery stenosis is suspected)

Additional referral information (useful for processing the referral)

• History of smoking, alcohol or drug use (including recreational drugs)
• Ethnicity (with Aboriginal and Torres Strait Islander population at risk)
• ECG and echocardiogram results
• Any investigations relevant to co-morbidities or where results exclude other secondary causes e.g. sleep study, endocrine tests

Other useful information for management (not an exhaustive list)

• Refer to Healthpathways or local guidelines

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information 

• General Referral Information
• Detailed history of nephrolithiasis episodes
• Urine microscopy for evaluation of urinary sediment and urine albumin creatinine ratio
• FBC, ELFT, urea, creatinine, eGFR, calcium, Mg and PO₄ results
• Ultrasound (kidney, ureters and bladder) or CT results

Additional referral information (useful for processing the referral)

• Family History of chronic kidney disease and /or calculi
• Stone analysis
• Record of any previous urinalysis and urinary biochemistry (if available)
• Record of any previous calculus biochemistry (if available)
• BP

Other useful information for management (not an exhaustive list)

• Refer to Health pathways or local guidelines

Generally, patients with systemic illness, renal tubular dysfunction or metabolic involvement would require referral to nephrology rather than urology where possible

Patient resources

• Kidney Health Australia – Kidney stones

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.

Essential information 

• General Referral Information
• Presence of comorbid conditions such as hypertension, diabetes, vascular disease or known CKD
• Current medications, medication history and allergies
• Examination of the 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 midstream M/C/S (including testing for red cell morphology and casts preferable)
• Urine albumin creatinine ratio (ACR) or urine protein creatinine ratio (PCR) (ideally early morning sample but a random sample is acceptable)
• Timeline of the symptoms

Additional referral information (useful for processing the referral)

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

Other useful information for management (not an exhaustive list)

* At the level of nephrotic range proteinuria, albumin accounts for 60-7-% 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 ration testing can assist with diagnostic evaluation
• 24-hour quantification: Where urine ACR is significantly elevated (>100 mg/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 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

• Proteinuria Consensus Statement, 2012

Patient resources

• Kidney Health Australia – Albuminuria fact sheet

Categorisation

Available appointments are provided to our patients based on clinical priority. A process of categorisation ensures safety and equity of access.