Referral

This page summarises 'when to refer' for specialist care. This is dealt with in more detail on the linked pages.

There will be differing local pathways and processes for some referrals. Frequently, advice by email or telephone may help in reaching a decision. Follow local protocols when provided.   Seek specialist advice where patients fall outside protocols. 

Jump to 'what to send' 

When to refer to specialist services (summary)
According to eGFR (ml/min/1.73m2)
<15
 Usually immediate referral or discussion (exceptions discussed on stage 4-5 page)
15-29
 Urgent referral or discussion; or routine referral if known to be stable (exceptions discussed with further info about management of Stages 4/5 CKD
30-59
 Routine referral indicated if:
  • Progressive fall in GFR/rise in serum Creatinine
  • Non-visible haematuria more on haematuria
  • Proteinuria, if ACR>70 or PCR >100mg/mmol more info on Proteinuria
  • Unexplained anaemia (Hb <110g/l), abnormal potassium, calcium or phosphate

Further info about management and referral of Stage 3 CKD
60+
 Referral not required unless other evidence of kidney disease (e.g. likely genetic diagnosis, urinary abnormalities, see below)
Further info about management and referral of Stages 1 and 2 CKD
   
Other indications for referral
Acute renal failure
 Immediate referral/discussion - most patients with acute renal failure unless the cause and solution are obvious.
More on deteriorating renal function
Proteinuria
 Routine referral - urinary ACR>70 or PCR>100mg/mmol; or ACR>30 or PCR>50mg/mmol with microscopic haematuria
Urgent referral - Heavy proteinuria with low serum albumin (nephrotic syndrome).
Further info about proteinuria
Haematuria
 Visible haematuria with negative urological investigations or with strong renal features
Invisible haematuria with proteinuria as above
Further info about haematuria
Hypertension
 Immediate referral - malignant hypertension
Routine referral - uncontrolled (>150/90) BP despite 4 agents at therapeutic doses in a patient with CKD
Further info about hypertension in CKD
Systemic illness
 Suspicion of renal involvement from a systemic illness should lead to urgent referral or discussion. 
 

Information that it is valuable to send with referral

  • General medical history - particularly noting urinary symptoms, previous blood pressures, urine testing.
  • Medication history
  • Examination
  • Urine dipstick result for haematuria and quantitation of proteinuria by ACR or PCR
  • Blood tests - Full blood count, urea and electrolytes. HbA1c if diabetic. If available, calcium, albumin, phosphate, cholesterol.
  • Previous tests of renal function with dates, back to normal renal function if possible (unless electronically available in specialist centre).
  • Imaging - results of renal imaging if undertaken (according to local circumstances, pre-ordering may speed assessment)