What are the key indicators for referring a patient with suspected chr

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

Refer adults with CKD for specialist assessment if they have:

A 5-year risk of needing renal replacement therapy of greater than 5% (measured using the 4-variable Kidney Failure Risk Equation) .
An albumin:creatinine ratio (ACR) of 70 mg/mmol or more, unless caused by diabetes and managed appropriately .
An ACR of more than 30 mg/mmol (ACR category A3), together with haematuria .
A sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months .
A sustained decrease in eGFR of 15 ml/min/1.73 m2 or more per year .
Hypertension that remains poorly controlled despite the use of at least 4 antihypertensive medicines at therapeutic doses .
Known or suspected rare or genetic causes of CKD .
Suspected renal artery stenosis .

What are the key indicators for referring a patient with suspected chronic kidney disease to a nephrologist?