Acute decline in kidney function

ADULT

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    NB Please call your local Kidney Medicine/Nephrology service if there is any doubt regarding the urgency of referral for an unwell patient

    PAEDIATRIC

    NB: Please call your local Kidney Medicine/Nephrology service if there is any doubt regarding the urgency of referral for an unwell patient

    Congenital anomalies of the kidney and urinary tract

    • Poor urinary stream in neonate / suspected posterior urethral valves
    • Previously undiagnosed kidney impairment in association with congenital structural malformations

    Haematuria / Glomerular disease

    • Suspected glomerulonephritis (ie haematuria and proteinuria) with acute kidney injury, hypertension or where the patient is systemically unwell

    Hypertension

    • Severe hypertension >(>95th centile +30 mmHg) or with any of the following concerning features
      • headache
      • confusion
      • blurred vision
      • retinal haemorrhage
      • reduced level of consciousness
      • seizures
      • proteinuria
      • papilloedema
      • signs of heart failure
      • chest pain


    Proteinuria / nephrotic syndrome

    • Nephrotic syndrome (proteinuria with urine PCR > 200g/mol) with any of the following concerning features:
      • significant peripheral oedema
      • signs of pulmonary oedema
      • severe hypertension
      • signs of DVT/PE
      • infection
      • acute kidney injury

    Kidney stones

    • Suspected urolithiasis / nephrolithiasis with infection or severe pain
    • Suspected urinary retention/obstruction (eg anuria, oliguria)

    Other

    • Any acute kidney injury or significant decline in kidney function where the treating doctor believes the patient requires urgent hospital care
    • Oliguria/anuria
      • Severe acute electrolyte disturbance for example:
      • hyperkalemia with K+ > 6.5 mmol/L OR > 6.0 mmol/L with ECG changes
      • hypokalemia with K+ < 2.5 mmol/L OR < 3.0mmol/L with symptoms
    • Severe metabolic acidosis (HCO3 < 15mmol/L)
    • Kidney transplant recipients with an acute decline in kidney function
    • Suspected glomerulonephritis (proteinuria and haematuria) associated with acute kidney injury

    ADULT

    NB: Please call your local Kidney Medicine/Nephrology service if there is any doubt regarding the urgency of referral for an unwell patient

    Acute decline in kidney function

    • Any acute kidney injury or significant decline in kidney function where the treating doctor believes the patient requires urgent hospital care (especially if evidence of abrupt increase in serum creatinine by > 50% of baseline)
    • Oliguria/anuria
    • Severe acute electrolyte disturbance for example:
      • hyperkalemia with K+ > 6.5 mmol/L OR > 6.0 mmol/L with ECG changes
      • hypokalemia with K+ < 2.5 mmol/L OR < 3.0mmol/L with symptoms
      • severe metabolic acidosis (HCO3 < 15mmol/L)
    • Kidney transplant recipients with an acute decline in kidney function (e.g. > 20% increase in serum creatinine)
    • Suspected glomerulonephritis (proteinuria and haematuria) associated with acute kidney injury

    Chronic Kidney Disease (CKD)

    • Severe acute electrolyte disturbance for example:
      • hyperkalemia with K+ > 6.5 mmol/L OR > 6.0 mmol/L with ECG changes
      • hypokalemia with K+ < 2.5 mmol/L OR < 3.0mmol/L with symptoms
      • severe metabolic acidosis (HCO3 < 15mmol/L)
    • Severe hypertension especially when accompanied with declining kidney function
    • Patients with severe uraemic symptoms or signs
    • Evidence of acute fluid overload or heart failure in a patient with known CKD
    • Kidney transplant recipients with acute intercurrent illness
    • Peritoneal or haemodialysis patients with acute issues or problems with dialysis access (eg vascular access issues or peritoneal dialysis catheter issues)
    • Peritoneal dialysis patients with suspected peritonitis (abdominal pain, cloudy dialysis fluid)

    Cystic kidney disease

    • Significant cyst haemorrhage, suspected septicaemia related to cyst infection, suspected rupture of berry aneurysm

    Glomerular Disease

    • Suspected Glomerular Disease (proteinuria and haematuria) with acutely declining kidney function or patient systemically unwell

    Haematuria

    • Severe macroscopic haematuria

    Hypertension

    • Hypertensive emergency (for example BP > 220/140)
    • Severe hypertension with systolic BP > 180mmHg with any of the following concerning features:
      • headache
      • confusion
      • blurred vision
      • retinal haemorrhage
      • reduced level of consciousness
      • seizures
      • proteinuria
      • papilloedema
      • signs of heart failure
      • chest pain
      • acute kidney injury
      • suspicion of aortic dissection
      • new neurological deficits

    If suspected pregnancy induced hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric services where possible.

    Nephrolithiasis – recurrent

    • Suspected urolithiasis / nephrolithiasis with infection or severe pain
    • Suspected urinary retention/obstruction (eg anuria, oliguria)

    Proteinuria

    • Nephrotic syndrome (proteinuria > 3.5 grams/24 hours OR urine ACR > 300mg/mmol* or PCR > 300g/mol*) with any of the following concerning features:
      • significant peripheral oedema
      • signs of pulmonary oedema
      • severe hypertension
      • signs of DVT / PE
      • infection
      • acute kidney injury

    Other

    • Kidney transplant patients with significant intercurrent illness (e.g. diarrhoea and vomiting)
    • Refer to local Healthpathways or local guidelines
    • Consider withholding ACE-Inhibitor, ARB, diuretics, NSAIDs, metformin, sulphonylureas, SGLT2 inhibitors
    • Consider dose adjustment of medication

    Clinician resources

    Patient resources

Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)
  • Abrupt and significant decline in kidney function that does not require referral to emergency but where specialist review is required, for example
    • increase in serum creatinine by > 50% of baseline within the last 4 weeks
    • increase in serum creatinine by >26.5µmol/L in the last 7 days
Category 2
(appointment within 90 calendar days)
  • No Category 2 criteria
Category 3
(appointment within 365 calendar days)
  • No Category 3 criteria

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention not otherwise accessible to the patient
  • For advice regarding management
  • To engage in an ongoing shared care approach between primary and secondary care
  • Reassurance for GP/second opinion
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)

2. Essential referral information Referral will be returned without this

  • Presence of comorbid conditions such as hypertension, diabetes or vascular disease
  • List of medications
  • BP records (if available)
  • Serial ELFTs including urea, creatinine & eGFR results
  • FBC
  • Urine albumin creatinine ratio (ACR) or urine protein creatinine ratio (PCR) (ideally early morning sample, but a random sample is acceptable)
  • Urine midstream M/C/S (including testing for red cell morphology and casts preferable)
  • Ultrasound (kidney, ureters & bladder) and any other available relevant imaging results

3. Additional referral information Useful for processing the referral

  • Timeline of symptoms
  • Presence or absence of oedema
  • Other supportive investigative tests indicated including:
    • If urine ACR>30mg/mmol or haematuria present with acute decline in kidney function, include ANCA, ANA, ENA & anti DNA Abs, C3/C4 and Hepatitis B/C serology
    • If myeloma suspected, include paraprotein testing e.g. FLC, SEPP, Urine BJP

4. Request

  • Patient's Demographic Details

    • Full name (including aliases)
    • Date of birth
    • Residential and postal address
    • Telephone contact number/s – home, mobile and alternative
    • Medicare number (where eligible)
    • Name of the parent or caregiver (if appropriate)
    • Preferred language and interpreter requirements
    • Identifies as Aboriginal and/or Torres Strait Islander

    Referring Practitioner Details

    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of referral
    • Signature

    Relevant clinical information about the condition

    • Presenting symptoms (evolution and duration)
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco and other drugs use

    Reason for request

    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for GP/second opinion
    • For a specified test/investigation the GP can't order, or the patient can't afford or access
    • Reassurance for the patient/family
    • For other reason (e.g. rapidly accelerating disease progression)
    • Clinical judgement indicates a referral for specialist review is necessary

    Clinical modifiers

    • Impact on employment
    • Impact on education
    • Impact on home
    • Impact on activities of daily living
    • Impact on ability to care for others
    • Impact on personal frailty or safety
    • Identifies as Aboriginal and/or Torres Strait Islander

    Other relevant information

    • Willingness to have surgery (where surgery is a likely intervention)
    • Choice to be treated as a public or private patient
    • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

    • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

    • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Last updated: 20 January 2023

© State of Queensland (Queensland Health) 2023

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