NEPHROLOGY REFERRAL GUIDELINES by Joel Reynolds, M.D.
The following diagnostics are needed prior to nephrology referral and consultations
Proteinuria
– Evaluation with renal function panel, complete urinalysis, quantification of proteinuria with a random urine collection for protein to creatinine ratio (first morning void preferably), serum and urine protein electrophoresis.
– Significant proteinuria with a protein to creatinine ratio of >500 mg (without hematuria) should be referred for a nephrologic evaluation.
– Proteinura of >300 mg associated with gross or microscopic hematuria should be
referred for a nephrologic evaluation.
Hematuria
– Gross and microscopic hematuria should be initially referred for urologic evaluation.
– Hematuria should be referred for a nephrologic evaluation after completion of a urologic evaluation, if deemed necessary by a urologist.
– Obtain a renal ultrasound and /or CT scan of the abdomen and pelvis.
– Evaluation with a renal function panel and complete urinalysis.
Renal Failure
– Cr clearance of <60 ml/min and/or Cr >1.8 mgldl.
– Evaluation with a renal function panel, CBC, complete urinalysis, random urine for protein to creatinine ratio, protein electrophoresis, and PSA (males only).
– Obtain a renal ultrasound.
– Diabetic nephropathy should be treated with ACE or ARB medications and
aggressive blood pressure and glycemic control. Patients with frank proteinuria with
a protein to creatinine ratio >500 mg may be referred for a nephrologic evaluation.
– Provide most recent Hemoglobin A1C level.
Nephrolithiasis
– Obtain a renal ultrasound and /or CT scan of the abdomen and pelvis.
– Evaluation with renal function panel, complete urinalysis, uric acid, PTH, 24 hour protein >500 mg may be referred for a nephrologic evaluation.
– Complicated stone with hydronephrosis and /or hydroureter should be immediately referred for a urologic evaluation.
Nephrotic Syndromes with proteinuria, hyperlipidemia and hypoproteinemia
require timely nephrology referral.
– Evaluation with renal function panel, liver function panel, fasting lipid panel, quantification of proteinuria with random urine protein to creatinine ratio, serum and urine protein electrophoresis.
– Obtain a renal ultrasound.
Polycystic Kidney Disease (PCKD) and any genetic kidney disease should be
referred for a nephrologic evaluation.
– Evaluation with a renal function panel, urinalysis.
– Obtain a renal ultrasound and /or CT scan of the abdomen and pelvis.
Hypertension, moderate to severe, requiring more than three medications should be
referred for a nephrologic evaluation.
– Evaluation with a renal function panel, urinalysis, random urine for protein to creatinine ratio.
The following situations do NOT normally reguire nephrology consultations
– Acute Renal Failure — particularly with oliguria, anuria or hyperkalemia-requires
urgent evaluation in an acute care facility and is not appropriate for outpatient
consultation.
– Renal masses or complex renal cysts worrisome for malignancy should be
referred to a urologist for possible resection.
– Simple renal cysts are present in 20% of the population and do not require
nephrology evaluation.
– Hydronephrosis implies post-renal obstruction and almost always requires urologic
consultation to address the underlying anatomic pathology.
– Mild hyponatremia and hypokalemia are generally related to diuretic therapy. A
patient on diuretic therapy with a serum Na>126 meq/L and a serum k>3.1 meq/L do
not generally require a nephrologic evaluation.