Renal

Services available

The renal team are contactable via our clinical mailbox which is monitored within normal working hours: Clinical_Specialty_Renal@aapct.scot.nhs.uk

The kidney supportive care team can be contacted via their mailbox which is: Clinical_RenalSupportiveCare@aapct.scot.nhs.uk

Intro/background

The advice below is for adults. For children and young people, it is usually appropriate to refer if any albuminuria, haematuria, decreased GFR or hypertension (and to the Paediatric Renal Team).

When & how to refer

The referral should be through SCI gateway > University Hospital Crosshouse > Renal Medicine

Immediate referral for inpatient assessment

The Renal Consultant on call is contactable for emergency advice via switchboard. However if a patient with acute kidney injury (AKI) is clearly requiring admission, it is best to refer via the local Combined Assessment Unit.
- If the AKI is due to renal tract obstruction, then refer to Urology (unless there is a life-threatening biochemical disturbance or fluid overload that could need immediate renal replacement therapy)
New, very advanced chronic kidney disease (eGFR < 15)
Hypertensive emergency with renal involvement.
Hyperkalaemia
- Acute or dangerous hyperkalaemia is usually referred to the general medical take for same-day assessment.
- Dialysis patients should be discussed with Renal directly.

Urgent referral

Nephrotic syndrome (triad of oedema, hypoalbuminaemia and nephrotic range proteinuria of uPCR > 0.3 g/mmol or uACR > 220 mg/mmol)
- Most individuals with nephrotic syndrome should be seen by Renal urgently.
- If this is chronic and in the context of longstanding diabetes then a routine referral is appropriate.
Multi-system disease with evidence of renal involvement.
- Requires a urinalysis result showing haematuria and proteinuria and/or a climbing serum creatinine)

Routine referral

Declining eGFR:
- A sustained decrease in eGFR of >25% and a change in eGFR category within 12 months.
- A sustained decrease in eGFR of >15 ml/min per year.
Sustained proteinuria in the absence of urinary tract infection (UTI):
- uACR > 70 mg/mmol (or uPCR > 100 mg/mmol)
- uACR > 30 mg/mmol (or uPCR > 50 mg/mmol) with haematuria.
High absolute risk of progressing to end-stage kidney disease:
- This will depend on age, eGFR (ideally viewed over time on a graph), proteinuria and co-morbidities.
- CKD G3 in a patient aged <50 years old.
- 5-year risk of needing renal replacement therapy >5% (measured using UKidney Kidney Failure Risk Equation (KFRE) Calculator). uPCR can be converted to uACR using the Johns Hopkins University Urine Protein-Creatinine Conversion tool.
Haematuria if unexplained by urological causes:
- Refer persistent non visible haematuria in patients over 40 and any visible haematuria to Urology in the first instance.
- Refer to Renal if features to suggest a likely intrinsic renal cause (e.g. associated proteinuria or haematuria in association with a presumed viral infection)
Diabetes:
- Refer if progression (in GFR or proteinuria) is disproportionate to the duration / severity of diabetes (likely non-diabetic renal disease)
- Refer early if intensive multi-factorial intervention may help to prevent progression to stage 4 chronic kidney disease (CKD) (i.e. if not meeting blood pressure and glycaemic targets despite best management in primary care)
New diagnosis of hypertension in those aged <30 or in those <40 with high clinical suspicion of secondary hypertension.
Resistant hypertension.
- Defined as high blood pressure that remains above target despite the concurrent use of four antihypertensives, ideally including a diuretic, at maximum tolerated doses.
Known or suspected rare or genetic causes of CKD (e.g. family history, young patient, extra-renal syndrome)

Who not to refer for outpatient review

Chronic kidney disease (CKD) in the context of advanced frailty/multi-morbidity although we are always happy to discuss.
- Consider direct discussion with the Ayrshire Kidney Supportive Care team.
Early-stage CKD (e.g. GFR > 60; uPCR <50) – particularly if stable and likely due to common risk factors (e.g. hypertension, diabetes) – the focus here should be on cardiovascular risk reduction in the community but we are always happy to discuss.
Decline in renal function based on a single measurement.
UTIs (better to refer to the recurrent UTI service within Urology for difficult cases)
Kidney or urological cancers unless progressive CKD (managed by Urology/Oncology)
Simple kidney cysts (common and associated with aging, complex cysts should be referred to Urology.