How can I effectively manage a patient with nephritic syndrome in prim

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

Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

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 .
- Refer adults for specialist assessment if they have a urinary albumin:creatinine ratio (ACR) of more than 30 mg/mmol together with haematuria ,,.
- 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 ,.
- Consider discussing management with a specialist if there are concerns but the patient does not need to see a specialist directly ,,.
Blood Pressure Management:
- Assess for hypertension ,.
- 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 ,. Do not offer a combination of renin-angiotensin system antagonists ,.
- 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 ,. 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 ,.
- Refer to a nephrology specialist if hypertension remains uncontrolled despite the use of at least four antihypertensive drugs at therapeutic doses ,,.
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 ,. Clearly explain when discontinued medicines should be restarted ,.
- 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) .
Monitoring and Follow-up:
- Arrange regular follow-up in primary care, with frequency depending on clinical judgement ,.
- Monitor for disease progression ,.
- Monitor serum creatinine after any episode of acute kidney injury .
Patient Education and Lifestyle Advice:
- Offer education and information tailored to the severity and cause of CKD, associated complications, and the risk of progression .
- Discuss immediate treatment options, monitoring, prognosis, and support options with the patient .
- Encourage the patient to take exercise, achieve a healthy weight, and stop smoking .
- Offer dietary advice about potassium, phosphate, calorie, and salt intake appropriate to the severity of CKD . This should be provided alongside education, detailed dietary assessment, and supervision to prevent malnutrition . Do not offer low-protein diets (dietary protein intake less than 0.6 to 0.8 g/kg/day) .
- Inform the patient about their 5-year risk of needing renal replacement therapy, using jargon-free language .
- Support self-management by providing information about blood pressure, smoking cessation, exercise, diet, and medicines, enabling informed choices .
- Consider offering access to psychological support, such as support groups or counselling, to help with coping with CKD .

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

Key References

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

Key References

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