When should I refer a patient with nephritic syndrome to a nephrologist for further evaluation and management?

When considering referral of a patient with suspected nephritic syndrome to a nephrologist for further evaluation and management, the following criteria should be considered:

• Suspected Glomerulonephritis or Other Specialist Conditions:
  • Liaise with a nephrologist as soon as possible and within 24 hours if there is a possible diagnosis that may need specialist treatment, such as glomerulonephritis (indicated by haematuria and/or proteinuria on urine dipstick analysis), tubulointerstitial nephritis, systemic vasculitis with renal involvement, or myeloma ³,⁴,⁶.
  • Refer immediately if there are complications of acute kidney injury caused by urological obstruction, pyonephrosis, an obstructed solitary kidney, or bilateral upper urinary tract obstruction ⁶.
• Proteinuria and Haematuria:
  • Refer adults with an albumin:creatinine ratio (ACR) of 30 mg/mmol or more, together with persistent haematuria, after excluding a urinary tract infection (UTI) ¹,²,⁵.
  • For children and young people, refer if they have an ACR of 3 mg/mmol or more (confirmed on a repeat early morning urine sample) or haematuria ⁵.
• Acute Kidney Injury (AKI) and Complications:
  • Discuss management with a nephrologist as soon as possible and within 24 hours if there is stage 3 AKI, AKI with no clear cause, or an inadequate response to treatment in primary care ⁶.
  • Refer immediately for renal replacement therapy if hyperkalaemia, metabolic acidosis, symptoms or complications of uraemia (e.g., pericarditis, encephalopathy), fluid overload, or pulmonary oedema are not responding to medical management ⁶.
  • Arrange urgent hospital admission or same-day referral if there is likely stage 3 AKI, no identifiable cause for AKI, or suspected complications requiring urgent hospital management such as pulmonary oedema, uraemic encephalopathy, pericarditis, or severe hyperkalaemia (serum potassium of 6.5 mmol/L or more) ³,⁴.
• Chronic Kidney Disease (CKD) Progression and Complications:
  • Refer adults with a sustained decrease in 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 ⁵.
  • Refer children and young people with any decrease in eGFR ⁵.
  • Refer if hypertension remains poorly controlled despite the use of at least four antihypertensive drugs at therapeutic doses ¹,²,⁵.
  • Refer if there is a known or suspected rare or genetic cause of CKD ¹,²,⁵.
  • Refer if there is diagnostic uncertainty or suspected complications of CKD such as persistent metabolic acidosis, decline in nutritional status, or persistent hyperkalaemia ¹,².
  • Liaise with a nephrologist as soon as possible and within 24 hours if the patient has stage 4 or 5 chronic kidney disease ³,⁴,⁶.
• Other Considerations:
  • A history of renal transplant warrants liaison with a nephrologist as soon as possible and within 24 hours ³,⁴,⁶.
  • Consider discussing management with a specialist if there are concerns but the person does not need to see a specialist ¹,²,⁵.