Chronic kidney disease
Adult

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Emergency Referrals

Important

If you believe your patient requires immediate attention, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice.

Kidney transplant patients with significant intercurrent illness (eg diarrhoea and vomiting)

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

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

Severe hypertension (systolic BP >220/140~~180~~or >180/110 if under 50 years of age) with no known ischaemic heart disease, cardiomyopathy, or chronic kidney disease AND 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 gestational hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric services where possible
If hypertension service available refer to hypertension service

Kidney Stones

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

Useful Management Information

*At the level of nephrotic range proteinuria, albumin accounts for 60-70% of total urinary protein. Within the CPC, ACR > 300mg/mmol OR PCR > 300g/mol has been used for simplicity and ease of application.

Before waiting 3 months to refer, it is important to establish that there is no evidence of acute kidney injury

In the absence of other referral indicators, referral may not be necessary if the following conditions are met:
- Stable eGFR ≥ 30 mL/min/1.73m2
- Urine ACR < 30 mg/mmol (with no haematuria)
- Controlled blood pressure

The decision to refer or not must always be individualised, and particularly in younger individuals the indications for referral may be less stringent. Discuss management issues with a specialist by letter, email or telephone in cases where it may not be necessary for the person with CKD to be seen by the specialist.

Refer to HealthPathways or local guidelines

Clinician resources

Patient resources

Kidney Health Australia

Minimum Referral Criteria

Does your patient meet the minimum referral criteria?

Category 1 (appointment within 30 calendar days)	Stage 5 CKD (eGFR < 15) that does not require referral to emergency Stage 4 CKD (eGFR 15 – 29) with any of the following: severe complications (eg renal bone disease, acidosis, hyperkalaemia) symptoms of CKD (eg fatigue, restless legs, itch, weight loss, severe anaemia, mild uremic symptoms) multiple contributing comorbidities rapid deterioration Known CKD with severe anaemia (Hb <80g/L) Persistent nephrotic range proteinuria* (urine ACR > 220mg/mmol OR PCR > 350g/mol) NB: eGFR units: mL/min/1.73m2
Category 2 (appointment within 90 calendar days)	Stage 4 CKD (eGFR 15 – 29) that do not meet Category 1 criteria Stage 3a or b CKD with progressive deterioration in eGFR despite treatment (eg deterioration in eGFR >15mL/min/1.73m2 or > 25% over 12 months) CKD with resistant hypertension despite at least three antihypertensive agents including at least one diuretic
Category 3 (appointment within 365 calendar days)	Chronic anaemia (Hb 80-100g/L) with CKD Stage 3a or b where other causes have been excluded Persistent sub-nephrotic range macroalbuminuria (urine ACR 30-300mg/mmol OR PCR 60-300g/mol) CKD with uncontrolled hypertension that are not achieving blood pressure target CKD without clear diagnosis

Category 1 (appointment within 30 calendar days)

Stage 5 CKD (eGFR < 15) that does not require referral to emergency
Stage 4 CKD (eGFR 15 – 29) with any of the following:
- severe complications (eg renal bone disease, acidosis, hyperkalaemia)
- symptoms of CKD (eg fatigue, restless legs, itch, weight loss, severe anaemia, mild uremic symptoms)
- multiple contributing comorbidities
- rapid deterioration
Known CKD with severe anaemia (Hb <80g/L)
Persistent nephrotic range proteinuria* (urine ACR > 220mg/mmol OR PCR > 350g/mol)

NB: eGFR units: mL/min/1.73m2

Category 2 (appointment within 90 calendar days)

Stage 4 CKD (eGFR 15 – 29) that do not meet Category 1 criteria
Stage 3a or b CKD with progressive deterioration in eGFR despite treatment (eg deterioration in eGFR >15mL/min/1.73m2 or > 25% over 12 months)
CKD with resistant hypertension despite at least three antihypertensive agents including at least one diuretic

Category 3 (appointment within 365 calendar days)

Chronic anaemia (Hb 80-100g/L) with CKD Stage 3a or b where other causes have been excluded
Persistent sub-nephrotic range macroalbuminuria (urine ACR 30-300mg/mmol OR PCR 60-300g/mol)
CKD with uncontrolled hypertension that are not achieving blood pressure target
CKD without clear diagnosis

Standard Referral Information

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

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
All conservative options that have been pursued unsuccessfully prior to referral
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
Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use

Patient's Demographic Details

Full name (including aliases)
Date and country of birth
Residential and postal address including whether patient resides at an aged care facility
Telephone contact number/s – home, mobile and alternative
Medicare number (where eligible)
Name of the parent or caregiver (if appropriate)
Name of delegate and contact details (Department of Corrective Services)
Preferred language and interpreter requirements
Identifies as Aboriginal and/or Torres Strait Islander
Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

Full name
Full address
Contact details – telephone, fax, email
Provider number
Date of referral
Signature
Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

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.)

Essential Referral Information

Presence of comorbid conditions such as hypertension, diabetes or vascular disease
List of medications
FBC & ELFT results
Serial urea, creatinine & eGFR results demonstrating abnormal eGFR over at least 3 months
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)
Recent BP results
Ultrasound (kidney, ureters & bladder) or alternative renal imaging results

Additional Referral Information

Timeline of symptoms
Ethnicity (Aboriginal and Torres Strait Islander population especially at risk)
Iron studies, B12 and folate (essential if referring for anaemia)
Other supportive investigative tests indicated including:
If haematuria or macroalbuminurua present, include ANCA, ANA, ENA & anti DNA Abs, C3/C4 and Hepatitis B/C serology
If myeloma suspected, include paraprotein testing (especially if proteinuria) eg FLC, SEPP, BJP PTH
Family history of kidney disease
Kidney biopsy report (if available)

Send Referrals To

Smart Referrals

Preferred Method
About Smart Referrals

Secure Web Transfer

Gold Coast Health Service District

Internal Referrals

Nephrology qhRefer

Fax

(07) 5687 4497

Post

Booking and Referral Centre
Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215

Enquiries

1300 559 083

Related HealthPathways

No directly related pathways found

HealthPathways home page

Service Availability

Dr Jagadeesh Kurtkoti

Medical Director Nephrology/Renal Medicine

Facilities

Gold Coast University Hospital

If you would like to send a named referral, please address it to the specialist listed above, who will allocate a suitably qualified specialist to see the patient. Alternatively, you can view a full list of our specialists.

Chronic kidney diseaseAdult