What are the indications for referral to a nephrologist in patients with diabetic nephropathy?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 16 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

Referral to a nephrologist for patients with diabetic nephropathy is indicated in several situations:

  • Albumin:creatinine ratio (ACR): A specialist nephrology opinion is needed if there is a urine ACR greater than 30 mg/mmol ,. Referral is also indicated for an ACR of 70 mg/mmol or more, unless it is known to be caused by diabetes and is already appropriately treated . Additionally, an ACR of more than 30 mg/mmol (ACR category A3) together with persistent haematuria warrants referral ,,.
  • eGFR Changes: Refer if there is a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months . Referral is also indicated for a sustained decrease in eGFR of 15 ml/min/1.73 m or more per year .
  • Hypertension: Referral is needed if hypertension remains poorly controlled (above the person's individual target) despite the use of at least four antihypertensive medicines at therapeutic doses ,,.
  • Suspected Other Renal Disease or Causes: Consider referral if there are known or suspected rare or genetic causes of chronic kidney disease (CKD), such as polycystic kidney disease ,,. A specialist opinion is also needed if non-diabetic causes of renal disease are suspected ,. Suspect other renal disease if progressive retinopathy is absent, blood pressure is particularly high, proteinuria develops suddenly, significant haematuria is present, or the person is systemically unwell .
  • Suspected Renal Artery Stenosis: This should be suspected and referred if there is a reduction in eGFR of 30% or more within 3 months of starting (or increasing the dose of) a renin-angiotensin system antagonist ,,.
  • Complications of CKD: Refer if there are suspected complications such as a decline in nutritional status or malnutrition, persistent hyperkalaemia, end-stage renal disease (ESRD), renal anaemia, renal mineral and bone disorder, or persistent metabolic acidosis ,.
  • Risk of Renal Replacement Therapy (RRT): Refer adults with CKD if they have a 5-year risk of needing RRT of greater than 5% (measured using the 4-variable Kidney Failure Risk Equation) .
  • Diagnostic Uncertainty: Referral is appropriate if there is diagnostic uncertainty ,.

It is also advisable to consider discussing management with a specialist by letter, email, telephone, or virtual meeting if there are concerns, even if the person with CKD does not immediately need to see a specialist ,,.

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