How can I effectively manage a patient with nephritic syndrome in primary care while awaiting specialist input?

When managing a patient with suspected nephritic syndrome in primary care while awaiting specialist input, focus on prompt referral, blood pressure control, medication review, and patient education.

• Immediate Actions and Referral:
  • Discuss management with a nephrologist as soon as possible and within 24 hours, especially if there is a possible diagnosis that may need specialist treatment (e.g., glomerulonephritis) or if there is acute kidney injury with no clear cause ⁴.
  • Refer adults for specialist assessment if they have a urinary albumin:creatinine ratio (ACR) of more than 30 mg/mmol together with haematuria ³,¹,².
  • Arrange emergency admission if the patient presents with severe hyperkalaemia (potassium greater than 6 mmol/L), severe uraemia, or signs of fluid overload or dehydration ¹,².
  • Consider discussing management with a specialist if there are concerns but the patient does not need to see a specialist directly ³,¹,².
• Blood Pressure Management:
  • Assess for hypertension ¹,².
  • If the patient has hypertension and a urinary ACR over 30 mg/mmol, offer an angiotensin-receptor blocker (ARB) or angiotensin-converting enzyme (ACE) inhibitor first line, titrated to the highest licensed dose the person can tolerate ¹,². Do not offer a combination of renin-angiotensin system antagonists ¹,².
  • Aim to keep clinic systolic blood pressure below 130 mmHg (target range 120–129 mmHg) and diastolic blood pressure below 80 mmHg if the ACR is 70 mg/mmol or more ¹,². If the ACR is less than 70 mg/mmol, aim for a clinic systolic blood pressure below 140 mmHg (target range 120–139 mmHg) and diastolic blood pressure below 90 mmHg ¹,².
  • Refer to a nephrology specialist if hypertension remains uncontrolled despite the use of at least four antihypertensive drugs at therapeutic doses ³,¹,².
• Medication Review:
  • Review any potentially nephrotoxic drugs that may cause acute kidney injury (AKI) in severe intercurrent illness, and reduce or stop them as appropriate ¹,². Clearly explain when discontinued medicines should be restarted ¹,².
  • Exercise caution when giving non-steroidal anti-inflammatory drugs (NSAIDs) to people with chronic kidney disease (CKD) over prolonged periods, monitoring their effects on glomerular filtration rate (GFR) ³.
• Monitoring and Follow-up:
  • Arrange regular follow-up in primary care, with frequency depending on clinical judgement ¹,².
  • Monitor for disease progression ¹,².
  • Monitor serum creatinine after any episode of acute kidney injury ⁴.
• Patient Education and Lifestyle Advice:
  • Offer education and information tailored to the severity and cause of CKD, associated complications, and the risk of progression ³.
  • Discuss immediate treatment options, monitoring, prognosis, and support options with the patient ⁴.
  • Encourage the patient to take exercise, achieve a healthy weight, and stop smoking ³.
  • Offer dietary advice about potassium, phosphate, calorie, and salt intake appropriate to the severity of CKD ³. This should be provided alongside education, detailed dietary assessment, and supervision to prevent malnutrition ³. Do not offer low-protein diets (dietary protein intake less than 0.6 to 0.8 g/kg/day) ³.
  • Inform the patient about their 5-year risk of needing renal replacement therapy, using jargon-free language ³.
  • Support self-management by providing information about blood pressure, smoking cessation, exercise, diet, and medicines, enabling informed choices ³.
  • Consider offering access to psychological support, such as support groups or counselling, to help with coping with CKD ³.