When should I consider referring a patient with nephrotic syndrome to a nephrologist?

Consider referring a patient with nephrotic syndrome to a nephrologist if any of the following apply:

• They have an albumin-to-creatinine ratio (ACR) of 70 mg/mmol or more, which warrants nephrology assessment and initiation of an ACE inhibitor or ARB if not already started.
• They have an ACR between 30 and 70 mg/mmol with persistent proteinuria, where specialist advice should be considered.
• There is diagnostic uncertainty about the cause of the nephrotic syndrome or suspicion of a rare or genetic cause of chronic kidney disease (CKD).
• They have a sustained decrease in estimated glomerular filtration rate (eGFR) of 25% or more and a change in eGFR category within 12 months, or a sustained decrease in eGFR of 15 ml/min/1.73 m² or more per year.
• They have hypertension that remains poorly controlled despite the use of at least four antihypertensive drugs at therapeutic doses.
• There is haematuria accompanying proteinuria (especially if persistent after excluding urinary tract infection).
• They have complications of CKD such as renal anaemia, mineral and bone disorder, persistent metabolic acidosis, or nutritional decline.
• They are approaching end-stage renal disease and may require renal replacement therapy.

Referral should also be considered urgently if there are signs of acute kidney injury or complications such as severe hyperkalaemia, uraemia, fluid overload, or if renal replacement therapy is indicated.

These criteria align with NICE guidelines on chronic kidney disease assessment and management, which recommend referral based on proteinuria severity, eGFR decline, hypertension control, and diagnostic uncertainty among other factors ¹,²,³.