Suspected renal artery stenosis - for example,
- acute rise in creatinine of >20% associated with ACE inhibitors or Angiotensin receptor blockers (ARBs) - see How to start an ACE inhibitor
- recurrent pulmonary oedema in the absence of severe cardiac disease with clinical suspicion of renal artery stenosis
Stable, severe renal impairment with GFR 15-30mls (Stage 4 - explain stages - explain how to estimate GFR) - unless it is clear that the prognosis from other disease is short. A GFR of 30 corresponds to creatinine approx 240 micromol/l in a 30y man, but 160 in a 70y woman.
Moderately severe renal impairment with complications: (stage 3, GFR 30-60) with severe acidosis, disturbances of calcium, phosphate, or high parathyroid hormone. See guideline on management of CKD - stage 3
Moderately severe renal impairment with haematuria - GFR 30-60mls/min, (Stage 3 - explain stages - explain how to estimate GFR) - increased likelihood of inflammatory disease. Haematuria 2+ or more.
Proteinuria with haematuria - high probability of underlying renal disease. See guideline on proteinuria.
Isolated proteinuria - if protein/creatinine ratio >200mg/mmol, approx equivalent to 2g/day, without nephrotic syndrome. See guideline on proteinuria.
- Interpret with discretion in patients with serious comorbidity. Safe to monitor renal function and proteinuria and refer if deteriorates.
Macroscopic haematuria that is urologically unexplained. See guideline on macroscopic haematuria
Diabetes where progression out of keeping with disease (rapidity; no other microvascular complications, particularly retinopathy). Otherwise refer to nephrologist as for other patients with renal disease. See guideline on management of CKD - diabetes
Possible familial renal disease - for diagnosis or advice. Subsequent monitoring may not need to be at a renal unit.
Recurrent renal stones - nephrological and specialist dietetic review is valuable for multiple stone formers. More (brief) info from the EdRen Handbook.
Refractory hypertension (e.g. >150/90 despite agents from 4 complementary classes) if renal disease or renal artery stenosis is suspected.