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GP trainee
Interactive case history

Section 4 of 9 - Question 3 (of 10)

Chronic kidney disease: early identification

and management in adults - in association
with NICE
10013214 45

next

3. Testing reveals no evidence of proteinuria and his blood pressure is 125/85 mm Hg.
You check his eGFR 12 months later and it remains stable. So he does not need
referral for specialist assessment. However, you have other patients with CKD and
you review them.

Which one needs referral?

Your Correct
answer answer
a. 37 year old man, stage 3A, no diabetes, haematuria
b. 43 year old woman, stage 3B, diabetes, proteinuria (ACR
35 mg/mmol), no haematuria
c. 54 year old African man, stage 3B, blood pressure 160/95
 (taking four antihypertensives)

a : 37 year old man, stage 3A, no diabetes, haematuria

This man does not need referral.

b : 43 year old woman, stage 3B, diabetes, proteinuria (ACR 35 mg/mmol), no

haematuria

She does not need a referral.

c : 54 year old African man, stage 3B, blood pressure 160/95 (taking four
antihypertensives)

This man does need referral.

People with chronic kidney disease in the following groups should normally be
referred for specialist assessment:

o Stage 4 and 5 chronic kidney disease (with or without diabetes)

o Higher levels of proteinuria (urine albumin:creatinine ratio 70 mg/mmol or
more, approximately equivalent to protein:creatinine ratio 100 mg/mmol or
more, or urinary protein excretion 1 g/24 h or more) unless known to be due to
diabetes and already appropriately treated
o Proteinuria (urine albumin:creatinine ratio 30 mg/mmol or more,
approximately equivalent to protein:creatinine ratio 50 mg/mmol or more, or
urinary protein excretion 0.5 g/24 h or more) together with haematuria
o Rapidly declining estimate of GFR (eGFR) (more than 5 ml/min/1.73 m2 in
one year, or more than 10 ml/min/1.73 m2 within five years)
o Hypertension that remains poorly controlled despite the use of at least four
antihypertensive drugs at therapeutic doses
o People with, or suspected of having, rare or genetic causes of chronic kidney
disease
o Suspected renal artery stenosis.

You should take into account the individual's wishes and comorbidities when
considering referral.

People with CKD and renal outflow obstruction should normally be referred to
urological services, unless urgent medical intervention is required - for example, for
the treatment of hyperkalaemia, severe uraemia, acidosis, or fluid overload.

When testing for the presence of haematuria, use reagent strips rather than urine
microscopy.

o Evaluate further if there is a result of 1+ or more.

o Do not use urine microscopy to confirm a positive result.

Learning bite
 Consider discussing 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.

Once a referral has been made and a plan jointly agreed, it may be possible for routine
follow up to take place at the patient's GP surgery rather than in a specialist clinic. If
this is the case, criteria for future referral or re-referral should be specified.

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ISSN 1752-8526

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